Free 46355.FH11 - Indiana

APPLICATION FOR REAL ESTATE TRAINEE APPRAISER EXAMINATION / LICENSURE
State Form 46355 (R3 / 4-03) Approved by State Board of Accounts, 2003

Real Estate Appraiser Licensure and Certification Board Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, Indiana 46204-2700 T elephone: (317) 232-2980 www.in.gov/pla

INSTRUCTIONS: Please type or print this application in ink. Applicants must read Real Estate Appraiser Licensure and Certification statutes and rules before completing and filing the application. Application fee: $100.00 Make check or money order payable to: Indiana Professional Licensing. Application fee is nonrefundable and nontransferable.
1. Name of applicant (first, middle, last) 2. Residence address (number and street, city, state, ZIP code) 3. Mailing address (number and street, city, state, ZIP code) 4. Social Security number * 5. Residence telephone number ( ) Business telephone number ( )

* This agency is requesting the disclosure of your Social Security number in accordance

with IC 4-1-8-1. Disclosure is mandatory; this record cannon be processed without it. Social Security numbers will be made available to the Indiana Department of Revenue. 6. Date of birth (month, day, year)

APPRAISAL EDUCATION REQUIREMENTS List below all appraisal courses the applicant completed that consisted of at least fifteen (15) classroom hours and where the applicant successfully completed an examination. (No correspondence courses will be considered.) A classroom hour consists of fifty (50) minutes. Credit for duplicate courses will not be considered. T obtain credit for courses prior to July 1, 1990, applicant must submit verification in the form of a certificate, transcript or letter issued by the o course provider showing course title, date of successful course completion, and number of classroom hours. T obtain credit for courses after June 30, 1990, o applicant must submit verification in the form of a certificate of course completion which must include name of sponsoring organization, course title, identify course content, dates of course, certify minimum of fifteen (15) hours, hours completed, passing grade, and state name.

Education requirements: 90 hours
COURSE TITLE COURSE PROVIDER / SCHOOL NAME NUMBER OF HOURS MONTH / YEAR COMPLETED

TOTAL HOURS Attach separate sheet of paper if you need more room, using the above format. Staple to this application and mark addendum. (Continued on reverse)

Have you ever been denied a residential appraiser license, certified residential appraiser license, or certified general appraiser license by this state or any other state? (If Yes, provide a copy of the license denial.) Yes No Have you had a residential appraiser license, certified residential appraiser license, or certified general appraiser license suspended or revoked by any other state? (If Yes, provide a copy of the licensing board order.) Yes No Have you ever been convicted of a crime? (If Yes, provide a copy of the court order and any pertinent documents.) Yes No

NOTARY CERTIFICATE STATE OF COUNTY OF I,

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, having been 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 Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires