Broker Examination Application (Page 3 of 4) in pdf

56 SPOA 2103 (12-11)

Bureau of Professional and Occupational Affairs

State Real Estate Commission

POST OFFICE BOX 2649

HARRISBURG, PA 17105-2649

717-783-3658

717-787-0250 (FAX)

BROKER EXAMINATION APPLICATION

1. Applicant’s legal name: ________________________________________________________________________

2. Applicant’s home address: _____________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

3. Applicant’s social security number: ______________________________________________________________

4. Applicant’s date of birth: ______________________________________________________________________

5. Applicant’s phone number: ____________________________________________________________________

6. Applicant’s e-mail address: _____________________________________________________________________

7. Are you a high school graduate or hold a GED?

___YES ___NO

8. Have you ever been issued a real estate license by the Pennsylvania Real Estate Commission?

___YES ___NO

Type of license: __________________________ License Number:______________________________

9. Have you ever been issued a real estate license in another state?

___YES ___NO

Type of license: __________________________ Where: _____________________________________

10. Name and license number of your employer(s) wherein you earned your three years of real estate experience and dates of

employment:

_____________________________________________________________________________________

(Employer’s name and license number)

(Employment dates)

_____________________________________________________________________________________

(Employer’s name and license number)

(Employment dates)

_____________________________________________________________________________________

(Employer’s name and license number)

(Employment dates)

11. APPLICANT’S CERTIFICATION (Please check off each statement)

To the best of my knowledge, all information supplied in this application is true and correct.

I have read, understand and agree to comply with the Real Estate Licensing and Registration Act and the

Commission’s regulations.

I understand that any false statement made by me is subject to the penalties of 18 Pa.C.S. Section 4904 (relating

to unsworn falsification to authorities) and may result in a disciplinary sanction against my license.

___________________________________________________________

_______________

(Applicant’s Signature)

(Date)

Broker Examination Application Page 3

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