Statement Of Qualifications (Page 2 of 3) in pdf

School Owner/Administrator Statement of Qualifications

Form ED-106 continued

SCHOOL NAME:

APPLICANT NAME:

EXPERIENCE QUALIFICATIONS – Part II

Work History

If your experience is other than as school operator or instructor, include a detailed work history for the

preceding 10 years.

AND

Education

List your formal education. Include the name, city and state of the school or organization awarding the

degree. If not real estate related, you may wish to include a transcript.

AND

Licenses / Designations

List real estate related licenses, certifications, or designations you currently hold. Attach a copy of

certification(s) and designation(s) and, if issued by other than the Department, a copy of your license. If not

stated on the copy, attach a sheet stating the type of license, certificate or designation, name of the issuing

agency, date of issuance or award and expiration date.

COMPLETE AND ATTACH A LICENSE DISCIPLINARY ACTIONS DISCLOSURE form (LI-214/244)

ATTESTATION

By my signature below, I, as owner or operator/administrator of the School, acknowledge and agree:

• I have reviewed and will comply with all applicable provisions of statutes and rules including, without

limitation, A.R.S. §§ 32-2108, 32-2135, A.A.C. Title 4, Chapter 28, Article 4, and R4-28-101, Table 1,

R4-28-301, and R4-28-502 (D), and understand that approval may be withdrawn or denied if I do not

comply. I have the right to appeal such withdrawal or denial.

• I will file an application for course approval at least 30 days prior to presenting any new or

substantially revised course. I cannot advertise that a course is approved or issue credit to students

until, and unless the Department has approved it. I cannot issue credit after approval of the course

has expired.

• I will obtain instructor approval before I allow an instructor to teach a course for real estate credit on

behalf of the School. I understand that instructor approval is per individual course and instructors are

not given "blanket approval."

• I will maintain specified student records for five years. A.A.C. R4-28-404 (D)

• I will present, in bold face type, to each prospective student before enrolling or admitting the

student, the information required under R4-28-404 (E).

• I will allow the Commissioner to investigate the credentials or actions of the School or any of its

owners, administrators, directors, or instructors; to observe at any time a class submitted to the

Department for approval or approved by the Department; and to examine the School's books and

records used in connection with offering approved courses.

Applicant Signature:

Date:

Signature of School Owner (if Applicant is Administrator/Owner):

Date:

School Owner/Administrator Statement of Qualifications ED-106, Rev 07/11

Page 2 of 2

School Owner’s Initials _____

This form is available in alternate formats by contacting the Department's Business Services Office, 602-771-7767 to make your needs known.

Statement Of Qualifications Page 2

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