Form Dos-1783-F-A - Real Estate 30 Hour Supplemental Course Approval Application

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New York State
 
Department of State
Division of Licensing Services
Bureau of Educational Standards
P.O. Box 22001
Albany, NY 12201-2001
(518) 486-3803
 
Real Estate 30 Hour Supplemental Course Approval Application
 
PLEASE READ CAREFULLY, AS INCOMPLETE APPLICATIONS WILL BE RETURNED.
There is no fee for this application.
»
All applications must be submitted 60 DAYS BEFORE the proposed course is to be conducted.
»
Annual registration period runs from September 1st to August 31st.
»
Attach to application: the final examination(s) with answer key, reference page for each question and where the question falls in
the curriculum. Distance Learning courses require additional information as indicated in Section 176.24.
 
1. PLEASE INDICATE THE TYPE OF COURSE.
 
CLASSROOM
DISTANCE LEARNING (INTERNET/COMPUTER BASED)
BOTH
 
2. EDUCATIONAL ORGANIZATION DATA
SCHOOL NAME
 
 
ADDRESS (NUMBER AND STREET; ROOM/SUITE DESIGNATION)
 
 
CITY
STATE
ZIP+4
COUNTY
 
 
E-MAIL ADDRESS (IF ANY)
 
 
 
COORDINATOR’S NAME (person authorized to submit application on behalf of entity and responsible for administering Department of State regulations)
TELEPHONE
(
)
 
DOES THIS INDIVIDUAL HOLD A NEW YORK STATE REAL ESTATE LICENSE?
YES
NO
 
HOME ADDRESS (NUMBER AND STREET)
TELEPHONE
 
(
)
CITY
STATE
ZIP+4
 
 
3. CLASSROOM COURSES ONLY
PRIMARY CLASSROOM COURSE LOCATION
LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
 
 
CITY
STATE
ZIP+4
COUNTY
 
 
4. CLASSROOM COURSES ONLY
SECONDARY CLASSROOM LOCATIONS
LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
 
 
CITY
STATE
ZIP+4
COUNTY
LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
CITY
STATE
ZIP+4
COUNTY
LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
CITY
STATE
ZIP+4
COUNTY
DOS-1783-f-a (Rev. 11/15)
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