Statement Of Qualifications printable pdf download

Arizona Department of Real Estate (ADRE)

DOUGLAS A. DUCEY

Governor

Education Division

JUDY LOWE

Commissioner

2910 N. 44

Street

Phoenix, AZ 85018

SCHOOL OWNER/ADMINISTRATOR

STATEMENT OF QUALIFICATIONS (ED-106)

Submit this form in conjunction with an application for (or under current) Real Estate School Certification Approval

(ED-100). This completed and signed form (ED-106) and substantiating documentation (described below) is required

for each natural person or, if the applicant is an entity, each officer, director, member, manager, partner, owner, trust

beneficiary holding 10% or more beneficial interest, stockholder owning 10% or more stock ("Owner"), and person

exercising control of the entity ("Administrator").

The following documentation is required for each Owner (as described above) and Administrator in addition to this

form before the School application can be considered complete:

Disciplinary Actions Disclosure form (LI-214/244);

A valid Fingerprint Clearance Card from the Arizona Department of Public Safety;

Proof of Legal Presence; and

Substantiating documentation as described in the Experience Qualifications (Parts I and II) below.

Applicant Name (print):

Telephone: (

)

_________

Residence Address:

_______

Mailing Address:

___

Fax #:

Email:

Social

Security #:

Date of Birth:

Driver's Lic. State/#:

I am an

owner of [or]

named administrator for(School Name)

EXPERIENCE QUALIFICATIONS INSTRUCTIONS: Attach a separate page with the following headings: Experience,

Work History, Education and Licenses/Designations. After each heading, print legibly or type the information

requested. If none, write "none" under the heading. Before filing this application with the Department, attach a copy

of any license, diploma, certificate or transcript cited in this application.

EXPERIENCE QUALIFICATIONS – Part I

(1) Do you have experience operating a school?

Yes

If yes, include the name and address of each school, name and telephone number of a school

representative, your title, a description of your authority and responsibilities, and starting and

ending dates.

(2) Did a school you operated close leaving students with tuition paid but classes cancelled?

Yes

If yes, attach a statement of facts including disposition of unearned tuition, steps taken to

accommodate students, and the name and telephone number of an individual the

Department may contact concerning the situation.

(3) Do you have experience teaching?

Yes

List your experience and provide the name and location of each school and the major content

areas of the course(s) you taught, starting and ending dates, general duration of course(s) and

frequency taught.

(4) Were you approved by the real estate regulatory agency in another state?

Yes

If yes, provide a detailed statement of the type of approval issued, the name of the agency

that issued the approval, and starting and ending dates of the approval.

School Owner/Administrator Statement of Qualifications

, ED-106, Rev 07/11

Page 1 of 2

School Owner’s Initials _____

Statement Of Qualifications

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