Form Il 505-0659 - Leasing Agent Duplicate Renewal Form

Form Il 505-0659 - Leasing Agent Duplicate Renewal Form - 2014 Page 2

2014 LEASING AGENT REINSTATEMENT

LICENSE NO.:

SPONSOR LICENSE NO.:

NAME:

SPONSOR NAME:

□

CHECK HERE IF CHANGE OF SPONSOR

ADDRESS:

(Include $25 fee)

ADDRESS LINE 2:

MANAGING BROKER NAME:

CITY, STATE, ZIP:

MANAGING BROKER LICENSE NO.:

□

CHECK HERE IF CHANGE OF ADDRESS

ALL QUESTIONS MUST BE ANSWERED – Incomplete applications will be returned.

YES

Are you more than 30 days in arrears on court ordered Child Support Payments?

CONTINUING EDUCATION REQUIREMENTS- (CHECK ONE ONLY).

I HAVE FULLY COMPLIED with the CE requirements for the 2014 reinstatement period. (CE MUST be completed prior to submission

of this reinstatement application.) DO NOT SUBMIT CE DOCUMENTATION WITH THIS APPLICATION.

I AM EXEMPT from the CE requirements in accordance with the Real Estate License Act of 2000.

I understand that if I provide false/fraudulent information, I could lose my license, be fined up to $25,000 or have other penalties assessed.

Therefore, I declare that I have examined this form, and to the best of my knowledge, all statements are true, correct, and accurate. In

addition, my signature authorizes the Illinois Department of Financial and Professional Regulation to conduct criminal background

investigations. I also certify that the sponsoring broker indicated above (or indicated on a completed 45-Day Permit Sponsor Card if

changing sponsors) is my sponsoring broker.

Printed Name___________________________________________________ E-mail address_________________________________________

Your Signature___________________________________________________________________________

Social Security Number____________________________________________________________________

Sex

(Disclosure of applicant's Social Security Number is mandatory pursuant to 42 U.S.C. 666(a)(13) and 5 ILCS 100/10-65(c)

for use under the State's child support enforcement program.)

Managing Broker Signature*________________________________________________________________

*Required only if changing sponsoring broker on 45-Day Permit Sponsor Card.

Managing Broker License #________________________________________________________________

IL 505- 0659 (Rev 9/14) This form has been approved by the Agency Forms Coordinator.

Form Il 505-0659 - Leasing Agent Duplicate Renewal Form - 2014 Page 2