Fillable ENERGY AUDITOR CHECKLIST AND APPLICATION (Nevada Real Estate Division)

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ENERGY AUDITOR CHECKLIST AND APPLICATION (Nevada Real Estate Division)

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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102
(702) 486-4033 / realest@red.nv.gov / http://red.nv.gov/
Revised 12/18/19 Page 1 of 5 Form 663
ENERGY AUDITOR
CHECKLIST AND APPLICATION
The filing of this application does not authorize the applicant to conduct any activity for which a license is required.
Prior to submitting this application, be sure each question has been completely, thoroughly, and honestly answered. This
application must be signed and notarized. Fees are non-refundable.
APPLICATION: Residents and non-residents 18 years or older, may apply with a complete application
Form 663. Attach the documents listed below and a fee of $350.00.
FINGERPRINT CARD: Attach to your application:
ONE complete fingerprint card, along with a $40.25 cashier check or money order made payable to
the Department of Public Safety. Personal checks, company checks, or cash will not be accepted.
OR
A verification of fingerprints taken electronically issued by an approved vendor. See Form 619 for a list
of vendors, fees, and their addresses.
RECORDS: Complete and submit the Location of Records Form 664.
TRAINING AND EXPERIENCE: Provide a copy of the certificate issued for certification or
accreditation by an organization approved by the Administrator. Provide proof of not less than 40 hours
of training.
INSURANCE: Proof of insurance: $100,000 Errors and Omissions and $100,000 General Liability in
the name of the applicant, the applicant’s business entity, or the applicant’s employer. The insurance
documents must include the name of the applicant as being covered under the policy.
FINGERPRINT BACKGROUND WAIVER: Complete the Nevada Department of Public Safety
waiver form attached to this application.
IDENTIFICATION: Please provide a photo of yourself approximately 2” x 2”. You may choose to
submit a clear copy of a driver’s license photo, passport photo, Immigration card photo, etc.
FEE: $350.00. Payment is accepted by check payable to Nevada Real Estate Division or NRED. Cash in
exact change and credit cards are accepted for in person transactions.
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102
(702) 486-4033 / realest@red.nv.gov / http://red.nv.gov/
Revised 12/18/19 Page 2 of 5 Form 663
ENERGY AUDITOR
ORIGINAL LICENSING APPLICATION
TYPE OR PRINT CAREFULLY: This application is to be completed personally by the candidate.
IMPORTANT: Only information deemed by law to be confidential shall be confidential (Social security number, background
investigation results.) Most information provided by an applicant for licensure is public information and must be provided upon
request. By policy, the Real Estate Division shall post (via the web site) and sell licensee lists which include the licensee’s name,
business address (even if same as home address), and business telephone number.
1. Nevada Resident: Yes No (“No,” must provide Form 656)
2. Personal Information Date:
First Name: Middle or Initial: Last Name:
Home Address:
City: State: Zip Code:
Mailing Address:
City: State: Zip Code:
Home Phone: Email:
Date of Birth: Last 4 of Social Security Number or Federal Taxpayer ID:
3. Business Information
If a corporation or fictitious name is registered, please attach a copy of the registration or filing with the Secretary of State
or County Clerk Office. Please list the address of the principle office below if different from home address.
Name of Business (if applicable):
Location Address:
Mailing Address:
County: Business Telephone Number:
Division Use Only:
Credential Number: EA. Issue Date: Processor Initials:
Receipt Number: Date: Processor Initials:
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102
(702) 486-4033 / realest@red.nv.gov / http://red.nv.gov/
Revised 12/18/19 Page 3 of 5 Form 663
4. Occupation:
List employers, past and present, for five years preceding date of application. Attach additional list if necessary. If
unemployed, please indicate as such and dates.
a. Occupation/Position:
Employer/Supervisor: Phone:
Address:
Employed from to
b. Occupation/Position:
Employer/Supervisor: Phone:
Address:
Employed from: to
c. Occupation/Position:
Employer/Supervisor: Phone:
Address:
Employed from: to
5. Child Support Declaration NRS 425.520
Please indicate in the appropriate box below which one of the provisions apply to you. Your application for the
issuance of this license will be denied if you do not complete this section.
PLEASE CHECK ONE BOX
I am not subject to a court order for the support of a child.
I am subject to a court order for the support of one or more children and AM IN COMPLIANCE with that order
or plan approved by the district attorney or other public agency enforcing the order for the repayment of the
amount owed in that order.
I am subject to a court order for the support of one or more children and NOT IN COMPLIANCE with that order
or plan approved by the district attorney or other public agency enforcing the order for the repayment of that
amount owed in that order.
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102
(702) 486-4033 / realest@red.nv.gov / http://red.nv.gov/
Revised 12/18/19 Page 4 of 5 Form 663
6. PERSONAL BACKGROUND: If you answer “yes” to the questions below, give full details, including the
administrative agency, court, title of proceeding, disposition, and any other pertinent information on an attached sheet.
Attach order of the court or agency which was rendered as a result of the proceedings and a detailed written
explanation. Both fingerprint cards are submitted for a State and Federal background investigation.
a. Have you or any business in which you are or were an owner, partner, officer or director ever involved
in an administrative proceeding regarding any professional or occupational license?
Yes No
b. Has any license issued to you or any partnership or corporation of which you were a member or officer
by any public authority been suspended or revoked?
Yes No
c. Has a surety company declined to be surety on any bond written on you in the two years prior to the date
of the application?
Yes No
d. Have you ever filed bankruptcy or has bankruptcy been filed against you? If filed within 7 years from
the date of this application, please provide a copy of the discharge.
Date of discharge:
Yes No
e. Have you ever been convicted of a felony, gross misdemeanor, or misdemeanor? Yes No
f. Are you presently on parole or probation or paying any restitution? Yes No
g. Have you ever been convicted of, or are you under indictment for or have you entered a plea of guilty or
nolo contendere to forgery, embezzlement, obtaining money under false pretenses, larceny, extortion,
conspiracy to defraud or any crime involving moral turpitude?
Yes No
7. DECLARATION OF APPLICANT:
I hereby certify under the penalty of perjury that the answers contained in this application are true and correct; and I understand:
That if I am subject to a court order for support of one or more children and I am not in compliance with that order or plan, my
application for a certificate or renewal of a certificate will be denied.
That I will faithfully comply with all the statutes and regulations pertaining to the conduct of the Licensed Energy Auditor in the
State of Nevada.
That by signing this application, I authorize any person or institution to which reference is made by me, in connection with the
application, to release or divulge to the Nevada Real Estate Division any information in the possession of such person or
institution regarding me.
Signature of Applicant:
ss. State
County
This instrument was acknowledged before me on by .
SEAL Signature of Notary Public:
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102
(702) 486-4033 / realest@red.nv.gov / http://red.nv.gov/
Revised 12/18/19 Page 5 of 5 Form 663
REPORT OF EXISTENCE OF NEVADA BUSINESS LICENSE
Pursuant to NRS 645C
All applicants MUST complete this section. Please select ONE option.
I have a Nevada business license number assigned by the Nevada Secretary of State upon compliance
with the provisions of NRS Chapter 76.
My Nevada business license number is:
I have applied for a Nevada business license with the Nevada Secretary of State upon compliance with
the provision of NRS Chapter 76 and my application is pending.
I do NOT have a Nevada business license number.
The Real Estate Division is not the arbiter of determining whether the applicant needs a business license.
Information about the Nevada business license can be found on the Secretary of State’s website at:
http://nvsos.gov
ARE YOU A VETERAN? YES NO
0505RCCD-003(07/2017rev)
Fingerprint Background Waiver Page 1 of 2
Fingerprint Background Waiver
As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based
criminal history record check for a noncriminal justice purpose you have certain rights which are
discussed below.
1. You must be notified by the Nevada Real Estate Division (name of requesting agency)
that your fingerprints will be used to check the criminal history records of the FBI and the
State of Nevada.
2. If you have a criminal history record, the officials making a determination of your suitability
for the job, license or other benefit for which you are applying must provide you the
opportunity to complete or challenge the accuracy of the information in the record. You may
review and challenge the accuracy of any and all criminal history records which are returned
to the submitting agency. The proper forms and procedures will be furnished to you by the
Nevada Department of Public Safety, Records Bureau upon request. If you decide to challenge
the accuracy or completeness of you FBI criminal history record, Title 28 of the Code of
Federal Regulations Section 16.34 provides for the proper procedure to do so:
16.34 - Procedure to obtain change, correction or updating of identification
records. If, after reviewing his/her identification record, the subject thereof
believes that it is incorrect or incomplete in any respect and wishes changes,
corrections or updating of the alleged deficiency, he/she should make application
directly to the agency which contributed the questioned information. The subject of
a record may also direct his/her challenge as to the accuracy or completeness of any
entry on his/her record to the FBI, Criminal Justice Information Services (CJIS)
Division ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306.
The FBI will then forward the challenge to the agency which submitted the data
requesting that agency to verify or correct the challenged entry. Upon the receipt of
an official communication directly from the agency which contributed the original
information, the FBI CJIS Division will make any changes necessary in accordance
with the information supplied by that agency.
3. Based on 28 CFR § 50.12 (b), officials making such determinations should not deny the
license or employment based on information in the record until the applicant has been
afforded a reasonable time to correct or complete the record or has declined to do so.
4. You have the right to expect that officials receiving the results of the fingerprint-based
criminal history record check will use it only for authorized purposes and will not retain or
disseminate it in violation of federal or state statute, regulation or executive order, or rule,
procedure or standard established by the National Crime Prevention and Privacy Compact
Council.
0505RCCD-003(07/2017rev)
Fingerprint Background Waiver Page 2 of 2
5. I hereby authorize the Nevada Real Estate Division (name of requesting agency)
(name of requesting agency), to submit a set of my fingerprints to the Nevada Department
Public Safety, Records Bureau for the purpose of accessing and reviewing State of Nevada
and FBI criminal history records that may pertain to me.
In giving this authorization, I expressly understand that the records may include information
pertaining to notations of arrest, detainments, indictments, information or other charges for
which the final court disposition is pending or is unknown to the above referenced agency.
For records containing final court disposition information, I understand that the release may
include information pertaining to dismissals, acquittals, convictions, sentences, correctional
supervision information and information concerning the status of my parole or probation
when applicable.
6. I hereby release from liability and promise to hold harmless under any and all causes of legal
action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my
criminal history records search and provided information to the submitting agency for any
statement(s), omission(s), or infringement(s) upon my current legal rights. I further release
and promise to hold harmless and covenant not to sue any persons, firms, institutions or
agencies providing such information to the State of Nevada on the basis of their disclosures. I
have signed this release voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar
process, shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature
voluntarily appears below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEASE PRINT
Last Name
First Name
ADDRESS:
PLEASE PRINT
Applicant’s Signature:
Date:
Submitting Agency:
Nevada Real Estate Division
Address:
3300 West Sahara Avenue #350
Las Vegas, NV 89102
Agency Representative:
PLEASE PRINT
Last Name
First Name
Agency Representative Signature:
Date:
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Completed 28 December 2021

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