8. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
9. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention (P.T.I.);
or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
10. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete explanation.
(Attach additional sheets of paper to this application.)
11. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please proivde that name.
Last name First name Middle initial
_____________________ _______________________ ______________________________ ____________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ______________________________ ____________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ______________________________ ____________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ______________________________ ____________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
12. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
13. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
14. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
15. Have you ever been named as a defendant in any litigation related to the practice of real estate appraisal or other professional practice
in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
17. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
18. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of real estate appraisal or other professional practice in New Jersey, any other state, the District of Columbia
or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 12 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
19. What type of licensure or certication are you applying for? (Check one.)
Certication as a General Real Estate Appraiser
Certication as a Residential Real Estate Appraiser
Licensed Residential Real Estate Appraiser