Fillable FELONY APPLICANT FORM (Louisiana Louisiana Real Estate Commission)

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FELONY APPLICANT FORM (Louisiana Louisiana Real Estate Commission)

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The FELONY APPLICANT FORM (Louisiana Louisiana Real Estate Commission) form is 5 pages long and contains:

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  • 122 other fields

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Louisiana Real Estate Commission (LREC) aim to regulate real estate affairs in the state of Louisiana. LREC help protect the public interest during activites including real estate transactions.

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Felony Applicant 01/2020 Page 1 of 5
FELONY APPLICANT FORM
• All information shall be typed or printed in ink. Additional sheets of paper may be added if
necessary.
• Each question herein shall be answered truthfully and in its entirety. An incomplete or falsified
questionnaire may be returned unfiled as “REJECTED,” and your hearing will not be added to the
Commission agenda. You will be notified in writing if your application is rejected.
Full Name: _________________________________________________ DOB: ____________________
Last First M.I.
Address: _____________________________________________________________________________
Street Address Apartment/Unit #
_____________________________________________________________________________
City State ZIP Code
Phone: ____________________________________ SSN: _____________________________________
Email Address: ________________________________________________________________________
1. Complete a background check. You can find directions for completing a background check at
http://lrec.gov/enforcement/background-check
2. Attach a detailed personal statement, including, but not limited to, criminal history, felony
convictions, and the status of any charges currently pending against you.
3. Employment History: Provide employment history for the five years prior to the filing date of
this form.
From
(MM/YYYY)
To
(MM/YYYY)
Employer City, State Position/Duties
LOUISIANA REAL ESTATE COMMISSION
9071 Interline Avenue
Baton Rouge, LA 70809
(225) 925-1923 or (800) 821-4529 (LA only)
Felony Applicant 01/2020 Page 2 of 5
4. Out of State Real Estate License:
Issuing State: ________________________________ Date Issued: _______________________
Status: □ Active □ Inactive □ Expired □ Other: ________________________
Action Taken on License (if applicable):
□ Revoked □ Surrendered □ Suspended
□ Terminated □ Other: ________________________
5. Other Occupational/Professional License:
Issuing State: _______________ Type of License: ________________ Date Issued: __________
Status:
□ Active □ Inactive □ Expired □ Other: ________________________
Action Taken on License (if applicable):
□ Revoked □ Surrendered □ Suspended
□ Terminated □ Other: ________________________
6. One Professional Reference:
Name: _________________________________________________________________________
Title: __________________________________________________________________________
Company: ______________________________________________________________________
Phone: ________________________________________________________________________
Email: _________________________________________________________________________
7. If applicable, attach a letter of recommendation from a broker willing to sponsor you in the
event you become licensed. (Optional)
8. Criminal History (Include all felonies even if you have disclosed the offense(s) on another LREC
form or application).
Case number: __________________________________________________________________
Date crime committed: _____________________ Date sentenced: ____________________
Initial charge: __________________________________________________________________
Final charge: ___________________________________________________________________
Title of court: ______________________________ Parish of court: ___________________
Plea:
□ Guilty □ Not Guilty □ Nolo Contendre □ Other ________________________
Disposition (check all that apply):
□ Adjudicated Guilty □ Adjudicated Not Guilty
□ Probation Expired □ Shock probation □ Incarceration: __________ term
□ Deferred Adjudication □ Deferred Prosecution □ Restitution Ordered
□
Community Service Ordered
Felony Applicant 01/2020 Page 3 of 5
Case number: __________________________________________________________________
Date crime committed: _____________________ Date sentenced: ____________________
Initial charge: __________________________________________________________________
Final charge: ___________________________________________________________________
Title of court: ______________________________ Parish of court: ___________________
Plea:
□ Guilty □ Not Guilty □ Nolo Contendre □ Other ________________________
Disposition (check all that apply):
□ Adjudicated Guilty □ Adjudicated Not Guilty
□ Probation Expired □ Shock probation □ Incarceration: __________ term
□ Deferred Adjudication □ Deferred Prosecution □ Restitution Ordered
□
Community Service Ordered
Case number: __________________________________________________________________
Date crime committed: _____________________ Date sentenced: ____________________
Initial charge: __________________________________________________________________
Final charge: ___________________________________________________________________
Title of court: ______________________________ Parish of court: ___________________
Plea:
□ Guilty □ Not Guilty □ Nolo Contendre □ Other ________________________
Disposition (check all that apply):
□ Adjudicated Guilty □ Adjudicated Not Guilty
□ Probation Expired □ Shock probation □ Incarceration: __________ term
□ Deferred Adjudication □ Deferred Prosecution □ Restitution Ordered
□
Community Service Ordered
9. Attach a copy of all court minutes detailing the offense, the conviction, any related order, and
the penalties imposed.
10. Attach a letter from your probation or parole office either verifying your probation or parole
has been terminated or verifying the date upon which your probation or parole ends.
Regarding community supervision, parole, or probation:
Have you been released from any of the above:
□ Yes □ No
Have you ever violated the terms of any of the above:
□ Yes □ No Release Date: ________
Have you had your parole, community supervision or probation revoked:
□ Yes □ No
Date of Revocation: ___________________________________________________________
Explanation of circumstances leading to revocation and changes made to your sentence, if any:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Felony Applicant 01/2020 Page 4 of 5
11. Detail the events surrounding each felony arrest (include who, what, when, where, why, and
how). Attach additional sheets of paper, if necessary. Please note: Vague and unclear
explanations of the related events are not typically helpful and may result in additional
questioning during your hearing.
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Felony Applicant 01/2020 Page 5 of 5
12. Have you been arrested or otherwise involved in any other criminal activity, which may result
in a felony charge(s), since completion of sentencing for your most recent conviction? If yes,
please provide details.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
INFORMED CONSENT AND ACKNOWLEDGMENT
I certify I have personally prepared this form, and all of the information and documentation
included herein is true, correct, and complete to the best of my understanding. I hereby
acknowledge and agree I will furnish any other additional information or documentation
required by the Commission in verification of this application. Further, I hereby authorize and
consent an investigation conducted by the Commission into the matters addressed herein, and I
understand any information discovered in the investigation, which I have failed or refused to
include herein, may be presented at my hearing and may result in denial of my application
regardless of whether any other requirements for licensure have been met.
______________________________________________________ __________________
Signature Date
________________________________________________________________________________________________
Typed or Printed Name
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FELONY APPLICANT FORM (Louisiana Louisiana Real Estate Commission)

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Completed 22 January 2021

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