License Renewal Application Form - Dept. Of Commerce & Consumer Affairs State Of Hawaii Page 2
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2RENEWAL APPLICATION - Web doc
DEPT. OF COMMERCE & CONSUMER AFFAIRS STATE OF HAWAII
PROFESSIONAL & VOCATIONAL I.ICENSING DIVISION
P.O. BOX 3469, HONOLULU, HI 96801
This form is for the renewal of your license for the next license period,
JAN '13 - DEC '14 .
Instructions & information are on the enclosed sheet. DO NOT USE THIS FORM AFTER DEC 31 '13 .
REAL ESTATE COMMISSION
REAL ESTATE SALESPERSON
L
LICENSEE'S NAME & ADDRESS OF RECORD:
I
INACTIVE STATUS
C
E
N
S
E
D
A
LICENSE NO: RS -
T
A
FILE NO: Not applicable
By LICENSE EXPIRATION DATE DEC 31 12 ,
ON-TIME FEE
a TOTAL of
$
180.00
is due. <================================ ***
***
F
E
E
AFTER the LICENSE EXPIRATION DATE DEC 31 12 AND BEFORE DEC 31 13,
LATE FEE
S
a TOTAL of
$
230.00
is due. <================================ ***
***
Please make check or money order payable to: COMMERCE AND CONSUMER AFFAIRS
(DO NOT MAKE MULTIPLE PAYMENTS)
O
OTHER REQUIREMENTS or SPECIAL INSTRUCTIONS/lNFORMATlON:
INCOMPLETE APPLICATION WILL DELAY PROCESSING
T
TO BETTER ENSURE RECEIPT OF YOUR POCKET CARD BY 12/31/12,
H
SUBMIT YOUR RENEWAL BY 11/30/12.
E
R
PLEASE REFER TO THE "INSTRUCTIONS - RENEWING YOUR
REAL ESTATE LICENSE".
R
E
[ ] ADDRESS CHANGED? Check here and provide new mailing address below.
Q
_____________________________________________________________
U
I
_____________________________________________________________
R
E
M
This material can be made available for individuals with special needs. Please
E
call the Licensing Branch Manager at (808) 586-3000 to submit your request.
N
T
S
T
TO BE COMPLETED BY LICENSEE (Check your answers and provide additional information where requested):
O
If you never had any disciplinary actions or convictions to report OR if you previously reported disciplinary actions or convictions to the Licensing
B
Authority AND you had no disciplinary actions or convictions since that time, answer "No" to questions 1 and 3.
E
1) In the past 3 years has your license in this state or any other jurisdiction been formally disciplined by way of fine,
YES
NO
C
suspension, restriction, or revocation? ............................................................................................................................
O
YES
NO
M
2) Are there any disciplinary actions pending against you in this state or any other jurisdiction? ............................................
P
L
3) In the past 3 years have you been convicted of a crime in which the conviction has not been annulled or expunged?.......
YES
NO
E
T
E
EXPLAIN ANY "YES" RESPONSE ON A SEPARATE SHEET WITH DETAILED INFORMATION AND ATTACH SUPPORTING DOCUMENTS.
D
B
I understand that my license expires on the License Expiration Date shown on this form. I understand that if I fail to renew my license by
Y
the license expiration date I am unlicensed and shall not practice. I further understand that I may resume practice only after I have met all
L
I
appropriate restoration requirements.
C
I certify that the statements contained in this application are true and correct. I understand that misrepresentation is grounds for board
E
N
refusal to renew or subsequent suspension or revocation of license.
S
E
SIGNATURE OF LICENSEE _______________________________________________________________ DATE __________________________
E
HAVE YOU REMEMBERED TO:
TOTAL (ON TIME):
$ 180.00
TOTAL (LATE):
$230.00
FOR
1) Attach payment.
DCCA
REN......571
.... 50.00
REN......571
... 50.00
2) Answer questions.
ACCOUNTING
CRF......572
.... 90.00
PEN......578
... 50.00
3) Sign and date application.
OFFICE
4) If applicable, include
EF.........905
.... 40.00
CRF......572
... 90.00
ONLY
required documents.
EF.........905
.... 40.00
RS
LICENSE TYPE:
LICENSE NO.:
RS - INACTIVE
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