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
No
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.
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REC 1.02
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