Real Estate License Application (Form Rec 1.02) - North Carolina Real Estate Commission Page 2

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APPLICATION

1. Application FOR: (Select ONE)

License by EXAMINATION to be a NC Provisional Broker

License by EXAMINATION to be a NC Broker (Limited to applicants with a BROKER license in another

state or jurisdiction.)

REINSTATEMENT of a License Expired, Revoked, Cancelled, or Surrendered License for More Than Six

Months

2. Full Legal Name

Title:

Mr.

Ms.

First Name:

__________________________________________________________________________

Full Middle Name:

____________________________________________________________________

Last Name:

__________________________________________________________________________

Suffix (if any):

________________________________________________________________________

3. Mailing Address

PO Box or Street Address:

_______________________________________________________________

City:

______________________________________ _________________________________________

State: _______________________________________________________________________________

Nine-Digit Zip: _______________________________________________________________________

4. Legal Residence Street Address (If same as Mailing Address, leave blank.)

Street Address:

________________________________________________________________________

City:

_______________________________________________________________________________

State:

____________________________________.__________________________________________

9-digit Zip:

__________________________________________________________________________

5. Social Security Number:

___________________________________________________________________

6. Date of Birth:

___________________________________________________________________________

7. Phone:

_________________________________________________________________________________

8. Email Address:

___________________________________________________________________________

9. Examination Applicants Only. Please provide the following information from your N.C. prelicense course

completion certificate:

Instructor Code

School Code

Prelicense Course Completion Date

10. Is this your first time taking the NC license examination?

Yes

Application is NOT a Public Record. NOGS 93A-4(b2) provides that the information contained in your application is not subject to the Public Records Act unless

admitted as evidence in a hearing. The Commission will use your email and fax information to communicate with you. You may, upon licensure, provide the Commission

with email and fax information you wish to share with others such as continuing education providers.

Page 2 of 4

REC 1.02

REV 2/16