Free 51140.FH11 - Indiana

LICENSURE AS A REAL ESTATE APPRAISER VIA RECIPROCITY
State Form 51140 (R / 12-08) Approved by State Board of Accounts, 2009

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REAL ESTATE APPRAISER LICENSURE AND CERTIFICATION BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2060 E-mail: [email protected] www.pla.IN.gov

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

FOR OFFICE USE ONLY
Date received (month, day, year) Date fee paid (month, day, year) Application fee Date permit issuance (month, day, year) License number issued Receipt number

DO NOT WRITE ABOVE THIS LINE

I am applying for reciprocity as a (please check one)

Certified Residential Appraiser APPLICATION INFORMATION

Certified General Appraiser

Name of applicant (last, first, middle, maiden or previous) Address (number and street, city, state and ZIP code) Work telephone number ( ) Residential telephone number ( )

Date of birth (month, day, year)

Social Security number *

E-mail address

STATE OF LICENSURE

FROM WHAT STATES LICENSE ARE YOU APPLYING FOR A RECIPROCAL LICENSE? HOW MANY YEARS HAVE YOU HELD THIS LICENSE? TYPE OF LICENSE HELD LICENSE NUMBER

APPLICATION QUESTIONS If your answer is "yes" to questions 1 through 4, 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 government, or are criminal charges now pending against you? If yes you must include all court documentation with your application. (Minor violations of traffic laws resulting in fines do not apply.) 2. Have you ever been denied a license, certification, registration or permit to practice real estate appraising or any 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? Yes No

Yes Yes Yes

No No No

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)

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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, the Board or any of their 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 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 the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force as the original.

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

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