Fillable COOPERATIVE BROKER LICENSE $100 APPLICATION (Idaho Real Estate Commission)

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COOPERATIVE BROKER LICENSE $100 APPLICATION (Idaho Real Estate Commission)

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REE-005-03
Rev. 07/2020
IREC use only
License #:
__________________________
Receipt #
: __________________________
Approved:
__________________________
575 E. Parkcenter Blvd., Suite 180
Boise, Idaho 83706
Offi ce: (208) 334-3285
irec.idaho.gov
COOPERATIVE BROKER LICENSE
APPLICATION
$100
$100
INSTRUCTIONS: Submit this original, completed application form with the fee and ALL required
attachments. Applications that are illegible, incomplete, or missing the fee or required
attachments will be immediately returned without processing.
Applications that are faxed/emailed will not be accepted.
You are not licensed until IREC approves your license application. It is unlawful for you to engage in the business or act in the
capacity of a real estate licensee in Idaho without rst obtaining a cooperative license. Allow 10 business days to process your
completed application.
NOTE: Applications are processed in the order received. Updates on the status of license applications will NOT be given
over the phone. When your name and license number appear in the License Lookup on the IREC website, your coopera-
tive license has been approved.
Page 1 of 5
1. OUT-OF-STATE BROKER
Social Security Number Date of Birth Maiden name (or any other names used)
Full Legal Name Nickname (if used)
Home Phone Cell Phone Email address
Home Address (number, street, apt.)
City County State Zip Code
Brokerage Name Brokerage Phone Number
Brokerage Address
City County State Zip Code
2. RECORD OF LICENSURE You must presently hold an active broker level license from your state of licensure. A current
(less than 6 months old) certi ed license history must be attached.
NO YES
3. Have you ever had a real estate or other professional or occupational license revoked, suspended, or surrendered,
or the renewal refused, for a disciplinary violation involving fraud, misrepresentation or dishonest or dishonorable dealing,
in Idaho or any other jurisdiction?
NO YES
(If you answered “yes”, state the type of license, jurisdiction, date, disposition, and any other pertinent information on a
separate page and attach it to this application.)
4. ERRORS & OMISSIONS INSURANCE: (E&O insurance must have an e ective date on or before the date you submit
your application)
Rice Insurance Services Company (Commission group policy - attach a copy of the RISC certi cate of
coverage - for the out-of-state associate) - OR
Independent Coverage (attach completed, signed Certi cation of E&O Coverage form(s) (REE-141 and/or
REE-142) showing coverage for the out-of-state associate)
5. TRANSACTION DETAILS - Provide the information regarding the commercial transaction in the space provided.
Please note if this is a residential or agricultural transaction, you MUST contact IREC regarding licensing requirements.
Buyer/Seller Name: ________________________________________________________________________________
Address or Reasonable description of property being sought for purchase or listed for sale.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
6. Provide a list of the out-of-state associates that will be working on the transaction, if applicable. Must attach a completed
Addendum A of this application for each associate listed below.
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Name: ___________________________________________________________________________________________
REE-005-03 07/2020 Page 2 of 5
IREC use
ONLY
REE-005-03 07/2020 Page 3 of 5
7. PLEASE VERIFY YOU HAVE INCLUDED THE FOLLOWING REQUIRED ATTACHMENTS:
____ $100 license fee (check or credit card authorization form)..........................................................................................
____ Current (less than 6 months old) certied license history from your state of licensure................................................
____ Explanation of license disciplinary actions, if applicable (part 3).................................................................................
____ Errors & Omissions Certicate of Coverage (part 4)....................................................................................................
____ Addendum A for each associate that includes a current (less than 6 months old) certied license history
and proof of current E&O Insurance.............................................................................................................................
____ Idaho Broker Verication & Consent (Addendum B)....................................................................................................
8. Are you a military service member veteran? NO YES
9. Are you or your spouse on active military duty? NO YES (Fill out form REE-010 and attach)
10. I hereby appoint the Executive Director of the Idaho Real Estate Commission to act as my agent upon whom all judicial
and other process or legal notices directed to me may be served. I hereby consent that any lawful process against me
that is served upon the Executive Director shall be of the same legal force and validity as if served upon me and that
this authority shall continue in force so long as any liability remains outstanding in the state of Idaho. (Idaho Code 54-
2017(1)(d))
11. I acknowledge it is my responsibility to provide written notice to the Idaho Real Estate Commission of any change
of my personal name, address of personal residence, or personal telephone number within ten (10) days of the
change. (Idaho Code 54-2018(9))
12. I certify that the answers appearing hereon are true and correct to the best of my knowledge and belief. I understand
that my application may be denied, or my license inactivated, expired, terminated, suspended or revoked, and/or I may
be subject to disciplinary action, for the use of fraud, deception, misrepresentation, misstatement or omission or any
unlawful means in applying for or securing a license to act as a real estate broker in the State of Idaho. (Idaho Code
54-2019 and 54-2060(4))
_____________________________________________
Applicant Signature
NOTARY IS REQUIRED
State of )
) ss.
County of )
Signed (or attested) before me on ______________________________ by _______________________________________________.
Date Name of Individual (applicant)
___________________________________________________
Signature of Notary notary
seal
___________________________________________________
My Commission Expires
NOTICE: Because of rising costs associated with issuing a refund, it is the policy of IREC to refund overpayments of under $25 only if requested in writing within
30 days of IREC receipt of the overpayment. Overpayments of $25 or more will be automatically refunded. There is a $20 fee assessed for each check returned to
IREC for insucient funds.
IREC use
ONLY
REE-005-03 07/2020 Page 4 of 5
ADDENDUM A: OUT-OF-STATE ASSOCIATE INFORMATION
This page must be lled out for each out-of-state associate that will be involved with this transaction. Must attach a current
(less than 6 months old) certied license history along with proof of E&O insurance.
Full Legal Name Phone Number Email Address
Home Address (number, street, apt. #)
City State Zip Code
Home Mailing Address (number, street, apt. #), if dierent from above
City State Zip Code
RECORD OF LICENSURE You must presently hold an active real estate license from your state of licensure. A current
(less than 6 months old) certied license history must be attached.
NO YES
Have you ever had a real estate or other professional or occupational license revoked, suspended, or surrendered, or the
renewal refused, for a disciplinary violation involving fraud, misrepresentation or dishonest or dishonorable dealing,
in Idaho or any other jurisdiction?
NO YES
(If you answered “yes”, state the type of license, jurisdiction, date, disposition, and any other pertinent information on a
separate page and attach it to this application.)
ERRORS & OMISSIONS INSURANCE: (E&O insurance must have an eective date on or before the date you submit
your application)
Rice Insurance Services Company (Commission group policy - attach a copy of the RISC certicate of coverage for
the associate) - OR
Independent Coverage (attach completed, signed Certication of E&O Coverage form(s) (REE-141 and/or
REE-142) showing coverage for the out-of-state broker)
I hereby appoint the Executive Director of the Idaho Real Estate Commission to act as my agent upon whom all judicial and
other process or legal notices directed to me may be served. I hereby consent that any lawful process against me that is
served upon the Executive Director shall be of the same legal force and validity as if served upon me and that this authority
shall continue in force so long as any liability remains outstanding in the state of Idaho (Idaho Code 54-2017(1)(d)).
I acknowledge it is my responsibility to provide written notice to the Idaho Real Estate Commission of any change
of my personal name, address of personal residence, or personal telephone number within ten (10) days of the
change (Idaho Code 54-2018(9)). I certify that the answers appearing hereon are true and correct to the best of my
knowledge and belief.
_____________________________________________
Out-of-State Associate’s Signature
NOTARY REQUIRED:
State of )
) ss.
County of )
Signed (or attested) before me on ______________________________ by _______________________________________________.
Date Name of Individual (out-of-state associate)
___________________________________________________
Signature of Notary notary
seal
___________________________________________________
My Commission Expires
ADDENDUM B: LICENSED IDAHO BROKER INFORMATION
Full Legal Name Nickname (if used) Idaho Broker License Number
Brokerage Name Brokerage License Number Phone Number
Mailing Address (number, street, apt.)
City State Zip Code
Physical Address (number, street, apt.)
City State Zip Code
I acknowledge it is my responsibility as the Idaho broker to be in charge of the transaction from beginning to end. I further
acknowledge that any entrusted moneys received in a cooperative transaction may be handled only by myself as the
cooperating Idaho broker in accordance with section 54-2041, 54-2017(9) and 54-2060, Idaho Code.
By signing below I further acknowledge my responsibilities as the Idaho broker, to supervise and control the out-of-state
broker and any associates in accordance with section 54-2038, Idaho Code.
Signature: ____________________________________________________
Idaho Broker’s Signature
NOTARY REQUIRED:
State of )
) ss.
County of )
Signed (or attested) before me on ______________________________ by _______________________________________________.
Date Name of Individual (Idaho broker)
___________________________________________________
Signature of Notary notary
seal
___________________________________________________
My Commission Expires
REE-005-03 07/2020 Page 5 of 5
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COOPERATIVE BROKER LICENSE $100 APPLICATION (Idaho Real Estate Commission)

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Completed 28 December 2021

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