Form Il 505-0339 - Real Estate Continuing Education Instructor Application Page 3
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411. Real Estate Experience
Type of License
License Number(s)
Original Date of Issuance
Expiration Date
] Broker
[ ] Appraiser
[
] Other
[ ] Salesperson
[
12. If you have been admitted to practice law by the Supreme Court of Illinois or another jurisdiction include an affidavit
stating your real estate related experience. Also include a copy of your resume and a copy of your current Attorney Registration
Card.
Attorney Registration No.:
Date Admitted:
Length of Time in practice:
Specialty:
13. Advanced Professional Designation (Attach copy of Certification)
Type of Designation
Where Received
Date Received
14. Work History - - List your last four employers in reverse chronological order
Name of Employer
Address of Employer
Dates of Employment
Telephone No.
Position
15. Teaching Experience Only - - List employers in reverse chronological order
Name of Employer
Address of Employer
Dates of Employment
Telephone No.
Position
Under penalties of perjury, I declare that I have examined the application and all supporting documents and to the best of my
knowledge, they are true, correct and complete. I also acknowledge that upon any changes of status or change of address I will notify
the Illinois Department of Financial and Professional Regulation.
Signature of Applicant:
Date:
IL 505-0339 (Rev 7/10)
563
Page 2 of 2 CE Instructor
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