Real Estate License Application (Form Rec 1.02) - North Carolina Real Estate Commission Page 3

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Examination Applicants Only

(12)

NC Prelicense Course

Licensure in Another State

(Indicate basis for qualifying.)

Prelicense Course in Another State

Equivalent Education/Experience

(13)

License History: Have you ever held a real estate license in N.C. or elsewhere?

No If yes, provide details.

Yes

State

License No.

From Mo/Yr

To Mo/Yr

State

License No.

From Mo/Yr

To Mo/Yr

Salesperson:

Broker:

(14)

Places of Residence: List all residence addresses during the past seven (7) years. List present address first. (Enclose

additional sheet if needed.)

Street Address or Highway Number

City

County

State

From Mo/Yr

To Mo/Yr

Street Address or Highway Number

City

County

State

From Mo/Yr

To Mo/Yr

Street Address or Highway Number

City

County

State

From Mo/Yr

To Mo/Yr

(15)

Employment History: Are you currently employed?

Yes

Describe all employment during the past three (3) years, including self-employment or work as an independent contractor.

List present employment first. (Enclose additional sheet if needed. Indicate “NONE” for any period you were not employed.)

Name of Company

Street Address or Highway Number

City

State

Phone

(

)

Position

Duties

From Mo/Yr

To Mo/Yr

Name of Company

Street Address or Highway Number

City

State

Phone

(

)

Position

Duties

From Mo/Yr

To Mo/Yr

If the Answer to Question 16, 17 or 18 is “Yes,” You Should Also Read “Application Procedures For Applicants with Character

Issues” on Page 4 of this Application.

YES NO

(16)

Criminal Offenses: Have you ever been convicted of any criminal offense (felony or misdemeanor) or is there

any criminal charge now pending against you? (You must report all offenses for driving while impaired and

other traffic offenses classified as “criminal traffic” — exclude only minor traffic “infractions.”) [If “YES,” submit a

detailed written explanation in your own words describing the circumstances for each offense/pending charge. Also

submit a copy of the court judgment for any conviction (or arrest warrant or bill of indictment for any pending

charge) not shown on your criminal record report.].................................................................................................

(17)

Professional License Disciplinary Action: Have you ever been denied a real estate or other professional license

or been disciplined by an occupational licensing agency (license suspended, revoked, surrendered, reprimanded,

etc.) in N.C. or elsewhere; or are there currently any complaints pending against you in connection with any

professional license that you hold? [If “YES,” submit a detailed written explanation in your own words and a copy

of the licensing agency’s order if applicable.]............................................................................................................

(18)

Liens or Judgments: Are there any liens or unpaid judgments now outstanding against you due to your failure

to pay a debt? [If “YES,” submit a detailed written explanation in your own words of the circumstances and your

efforts to pay, as well as the name of the judgment creditor or lien holder (i.e., the party you owe), the amount and

date of the judgment or lien, and the current balance.]............................................................................................

(19)

Have you filed another license application with the Real Estate Commission within the past six months?

In making this application to the North Carolina Real Estate Commission for a real estate license under the provisions of Chapter 93A of the General Statutes of North

Carolina and the Rules of the Real Estate Commission, I swear (or affirm) that I am the applicant named herein and that all information provided in connection with

this application is true to the best of my knowledge and belief, with the understanding that any omissions, inaccuracies or failure to make full disclosures may be deemed

sufficient reason to deny permission to take an examination or to deny a license after examination or to withhold renewal of or suspend or revoke a license issued by the

Commission. I swear (or affirm) that I am a United States citizen, a non-citizen national, or a qualified alien under federal law. I authorize the North Carolina Real Estate

Commission to obtain or receive from any consumer reporting agency, as defined by the Fair Credit Reporting Act, any criminal history information and any consumer

credit information pertaining to me in public or private record sources.

(20) Signature:___________________________________________ Date:______________________

Page 3 of 4

REC 1.02

REV 2/16