Form 36071 - Application For Approval Of Real Estate Salesperson / Broker'S Course - Indiana Real Estate Commission Page 2

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This state agency is requesting disclosure of personal information that is necessary to ac-
APPLICATION FOR APPROVAL OF
complish the statutory purpose of this state agency under IC 24-34-1-12. Disclosure of this
REAL ESTATE SALESPERSON /
information is voluntary. Failure to provide any information may prevent this form from being
BROKER'S COURSE
processed.
Upon complet ion, this form will be treated as a public record.
State Form 36071 (R3 / 7-99)
Date of application (month, day, year)
RETURN TO: Indiana Real Estate Commission
302 W. Washington St., Rm. E034
Indianapolis, IN 46204
NAME AND ADDRESS OF SCHOOL
Name of school
Telephone number
(
)
Street address
City, state, ZIP code
NAME AND ADDRESSES OF DIRECTORS AND OFFICERS
If incorporated, list names and residence addresses of all directors and officers.
Name
Title
Street address (residence)
City, state, ZIP code
Name
Title
Street address (residence)
City, state, ZIP code
Name
Title
Street address (residence)
City, state, ZIP code
Name
Title
Street address (residence)
City, state, ZIP code
Attach:
a copy of the Certificate of Incorporation;
l
a Certificate of good standing of the corporation issued by the Secretary of the State of Indiana.
l
PROOF OF SURETY BOND
Submit proof of Surety Bonding in the amount of $10,000. SUBMIT BOND REPORTING FORM.
Submit copy of Accreditation Certificate.
NAME AND ADDRESS OF COURSE DIRECTOR
Name
Telephone number
(
)
Street address (residence)
City, state, ZIP code
Attach:
Detailed resume. Review 876 IAC 2-2-4(c) School Director Qualifications.
l
NAME AND ADDRESS OF PRINCIPAL INSTRUCTOR
Name
Telephone number
(
)
Street address (residence)
City, state, ZIP code
Attach:
Detailed resume;
l
Instructor Approval Application for each instructor.
l
NAME AND ADDRESS OF ADDITIONAL INSTRUCTORS
If additional space is needed for other instructors, list on a separate sheet and attach to this form.
Name
Telephone number
(
)
Street address (residence)
City, state, ZIP code
Name
Telephone number
(
)
Street address (residence)
City, state, ZIP code
Attach:
Detailed resume for each additional instructor.
l

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