APPLICATION FOR ACTIVATION OF BROKER LICENSE
State Form 55647 (R5 / 5-18)
INDIANA REAL ESTATE COMMISSION
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-3009
SECTION C - CONTINUING CERTIFICATES
SECTION A - LICENSEE INFORMATION
You must attach copies of your continuing education certificates. Your application cannot be processed without them.
If your answer is "Yes" to any question 1 - 4, 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. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor,
or felony in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
SECTION D - REACTIVATION QUESTIONS
DO NOT WRITE ABOVE THIS LINE
FOR OFFICE USE ONLY
Date fee paid (month, day, year) Receipt number
Page 1 of 2
4. Has disciplinary action ever been taken regarding any professional license, certification, registration, or permit that you currently
hold or have previously held?
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?
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?
Address of current business (number and street or rural route, city, state, and ZIP code)
Signature of Managing Broker
SECTION B - BROKER INFORMATION
Date signed (month, day, year)
Name of Managing Broker License number of Managing Broker
Telephone number of business
Name of Real Estate Broker Company License number of company
Name of applicant (last, first, middle, maiden)
Date of birth (month, day, year)
Address of applicant (number and street or rural route)
Social Security number
Telephone number (daytime)
City, state, and ZIP code
E-mail address (required)
Place of birth (city and state or country)
Are you the spouse of a member of the military who is assigned to a duty station in Indiana?
Are you an active duty member of the military? (Optional)
Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)
I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).
Race **Ethnicity **
License number to be activated
INSTRUCTIONS: 1. The fee for this application is $10.00, payable to the Indiana Professional Licensing Agency, in accordance with 876 IAC 5-3-1.
2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website at www.pla.IN.gov for the licensing requirements.
5. Continuing Education requirements to activate a broker license per 876 IAC 6-7:
a. If you received a broker license by completing a broker course and the required exam, you must complete the twelve (12)
hours of continuing education that is due for the current licensing year to qualify for activation.
b. If you received a broker license by operation of law because your salesperson license was in inactive or referral status on
July 1, 2014, you must complete the twenty-four (24) hour broker educational course to qualify for activation.
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
** This information is being requested for workforce statistical purposes only; disclosure is voluntary.