Form Il 505-0362 - 120-Day Student Leasing Agent Permit/application

Form Il 505-0362 - 120-Day Student Leasing Agent Permit/application - 2016

120-DAY STUDENT LEASING AGENT PERMIT/APPLICATION

ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION

Division of Real Estate

320 West Washington Street, 3

Floor

Springfield, Illinois 62786

Real Estate Licensing 800/560-6420

472

120-DAY STUDENT LEASING AGENT PERMIT/APPLICATION

STUDENT LEASING AGENT INFORMATION

(Note: Must be submitted within 24 hours of employment)

NAME __________________________________________ SOC SEC NO._____________________

MAILING ADDRESS ________________________________________________________________

CITY, COUNTY, STATE, ZIP CODE ___________________________________________________

DATE OF BIRTH

____________

TELEPHONE NO. ( _ _ _ ) _ _ _ - _ _ _ _

EMAIL ADDRESS: _________________________________________________

SPONSOR/FIRM INFORMATION

SPONSOR NAME ___________________________________ LICENSE NO. ___________________

D/B/A (IF APPLICABLE) ______________________________________________________________

MAILING ADDRESS _________________________________________________________________

CITY, STATE, ZIP CODE _____________________________________________________________

TELEPHONE NUMBER ( _ _ _ ) _ _ _ - _ _ _ _

I/We certify that the Student Leasing Agent Applicant is at least 18 years of age, has not been a Student Leasing Agent

permit holder or a Leasing Agent licensee within the past 2 years, and has a high school diploma or an equivalent course of

study (i.e., GED). I/We further certify that the Student Leasing Agent Applicant shall be subject to the standards of

practice and disciplinary provisions of a Leasing Agent licensee and the Managing Broker shall be responsible for the

activities and actions of the Student Leasing Agent as if the Student Leasing Agent was a Leasing Agent licensee.

_____________________________________

_______________________________

Student Leasing Agent Signature

Managing Broker Signature

_____________________________________

_______________________________

Date

Managing Broker License No.

$25 Fee Payable to the Illinois Department of Financial and Professional Regulation is required with this Form.

320 WEST WASHINGTON STREET SPRINGFIELD, ILLINOIS 62786 PHONE: 800-560-6420 FAX: 217-782-3390 TTY: 866-325-4949

IL 505-0362 (Revised 1/16)

Form Il 505-0362 - 120-Day Student Leasing Agent Permit/application - 2016