Form Dos-1503-F-A - Real Estate Qualifying Course Approval Application Page 2
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5.
DISTANCE LEARNING EXAM LOCATIONS ONLY (MUST BE NEW YORK STATE LOCATION)
PRIMARY EXAM LOCATION
LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
CITY
STATE
ZIP+4
COUNTY
6.
DISTANCE LEARNING EXAM LOCATIONS ONLY (MUST BE NEW YORK STATE LOCATIONS)
SECONDARY EXAM 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
7.
TYPE OF EDUCATIONAL ORGANIZATION OWNERSHIP
Is this organization an accredited College or University?
Yes
No*
If No*, Please complete one of the following:
INDIVIDUAL: (Please submit a certified copy of the Trade Name Certificate and complete the following for Owner.)
NAME
HOME ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP+4
PARTNERSHIP: (Please submit a copy of Partnership Agreement and complete the following for all Partners.)
NAME
HOME ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP+4
NAME
HOME ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP+4
CORPORATION: (Please submit a copy of the Certificate of Incorporation and complete the following for all officers and other individuals who own 5% or
more of the stock of this corporation. If needed, attach additional sheets.)
NAME
HOME ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP+4
NAME
HOME ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP+4
DOS-1503-f-a (Rev. 10/15)
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