Free 45664.FH11 - Indiana

APPLICATION FOR REAL ESTATE APPRAISER PERMIT FOR TEMPORARY PRACTICE
State Form 45664 (R6 / 10-06) Approved by State Board of Accounts, 2006

INSTRUCTIONS:

Please type or print all information.

REAL ESTATE APPRAISER LICENSURE & CERTIFICATION BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3009 E-mail: [email protected] http://www.in.gov/pla

* 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 Permit number Date fee paid (month, day, year) Receipt number

Date permit issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Permit for temporary practice as a:

Licensed residential appraiser

Certified residential appraiser TEMPORARY PERMIT HISTORY

Certified general appraiser

Have you ever applied to the Indiana Real Estate Appraiser Licensure and Certification Board for a permit for temporary practice?

Yes
If yes, how many previous temporary permits have you been granted?

No

Please provide issuance dates for previous permits (month, day, year)

APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden or previous) Social Security number * Name of appraisal business Appraisal business mailing address (number and street, city, state and ZIP code) Business telephone number Residential telephone number E-mail address Date of birth (month, day, year) Place of birth (city, state)

(

)

(

)

APPRAISAL ASSIGNMENT INFORMATION
Assignment address (number and street, city, state, and ZIP code) Date project will begin (month, day, year) How long will your assignment take? (indicate days, weeks, or months)

CURRENT EMPLOYER
Name of company Address (number and street, city, state, and ZIP code)

STATE LICENSURE / CERTIFICATION VERIFICATION Pursuant to 876 IAC 3-3-21, the Board will recognize, on a temporary basis, the license or certificate of an appraiser issued by another state, providing the following: (1) the appraisers business is of a temporary nature; (2) the appraiser registers with the Board; and (3) the license or certificate issued by the other state is appropriate for the type of property to be appraised in Indiana.
Type of license / certification held License / certification number State of issuance

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If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Letters from attorneys are not accepted 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 contendre to any offense, misdemeanor or felony in any state, or by the Federal courts, or any agency of the 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 appraising 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? 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 understand that continuing to practice appraising in Indiana after the completion of the assignment for which this temporary permit was issued is a violation of Indiana Code 25-34.1-8-12? APPLICATION AFFIRMATION I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes

No

Yes Yes Yes Yes

No No No No

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 or the Indiana Real Estate Appraiser Licensure and Certification Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Commission, 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 and the Indiana 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 Commission 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 the same.
Signature of applicant Date signed (month, day, year)

NOTARY CERTIFICATE STATE OF ________________________________________________ COUNTY OF ________________________________________________ SS:

I, _______________________________________________, being duly sworn on oath, say that I am the above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant Printed or typed name of applicant Date subscribed and sworn to Notary Public (month, day, year) Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires (month, day, year)

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