Free 46467.FH11 - Indiana

APPLICATION FOR REACTIVATION OF APPRAISER LICENSE
State Form 46467 (R3 / 2-08) Approved by State Board of Accounts, 2008

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REAL ESTATE APPRAISER LICENSURE & CERTIFICATION BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3009 www.pla.IN.gov

INSTRUCTIONS:

Please type or print clearly in ink.

*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY
Application fee Date National Registry checked (month, day, year) Date fee paid (month, day, year) Receipt number

Date of reactivation (month, day, year)

DO NOT WRITE ABOVE THIS LINE
SECTION A - REACTIVATION INFORMATION
License number to be reactivated Name (last, first, middle, maiden or previous)

Current residential address (number and street or rural route, city, state, and ZIP code) Social Security number * Work telephone number Date of birth (month, day, year) Other telephone number (home or cell) Place of birth E-mail address

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SECTION B - CONTINUING EDUCATION REQUIREMENTS TO REACTIVATE AN APPRAISER LICENSE In order to reactivate your appraiser license, you must have obtained the number of qualifying continuing education hours that would have been required by the provisions of 876 IAC 3-5-1 had the license been active, for all years the license was in inactive status; and have obtained seven (7) hours of Uniform Standards of Professional Appraisal Practice as required by 876 IAC 3-5-1.5(a)(1) that covered the version of the Uniform Standards of Professional Appraisal Practice in effect at the time this Application for Reactivation is filed. If you do not take the necessary continuing education hours during the renewal cycle, you may complete them at this time. Please remember that Broker Continuing Education and Real Estate Salesperson Continuing Education is not acceptable continuing education for real estate appraisers. You can obtain a list of approved continuing education courses, as well as online continuing education courses, on the Boards website, www.pla.in.gov.

SECTION C - CONTINUING EDUCATION VERIFICATION
Have you successfully completed the necessary continuing education hours in order to receive you appraiser license?

Yes

No

SECTION D - CONTINUING CERTIFICATES You must include copies of your continuing education certificates. If you do not include copies of your continuing education certificates, your license will not be reactivated.

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SECTION E - CONTINUING EDUCATION COURSES In the fields below, please record the necessary information about the continuing education courses you have taken to reactivate your license. You must include copies of all of your continuing education certificates needed to reactivate your license with this application. DATE OF COURSE (month, day, year) NAME OF COURSE PROVIDER HOURS

Please total the number of continuing education hours here: Page 2 of 3

0

SECTION F - REACTIVATION QUESTIONS If your answer is "Yes" to any question 1 - 4 , or No to question 5, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date, disposition, and court records. Letters from attorneys are not acceptable in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Have you ever been convicted of, pled guilty, or nolo contendere to any offense, misdemeanor, or felony in any state, or by the Federal courts, or any agency of government, or are criminal charges now pending against you? (Except for minor violations of traffic laws resulting in fines.) 2. Have you ever been denied a license, certification, registration or permit to practice real estate or any other profession in this or any other state? 3. Has any complaint been filed against you in the State of Indiana, or in any other state, regarding any professional license you currently hold or have previously held, or have you practiced real estate or appraising as defined by IC 25-34.1 without a license? 4. Has disciplinary action ever been taken regarding any professional license, certification, registration, or permit that you currently hold or have previously held? 5. Do you agree to promptly return your license certificate and pocket card if and when required by the Board and to conform to all relevant statutes and to the administrative rules promulgated by the Board? Yes Yes Yes Yes Yes No No No No No

SECTION G - APPLICANT AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, correct, and complete.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, of the Real Estate Appraiser Licensure and Certification Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of its authorized representatives in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the Real Estate Appraiser Licensure and Certification Board, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations and institutions any information which is material to my application, and I hereby specifically release the Agency and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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