Fillable FORM MUST BE COMPLETED BY VERIFYING BROKER, DEVELOPER (Nevada Real Estate Division)

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FORM MUST BE COMPLETED BY VERIFYING BROKER, DEVELOPER (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 12/11/2020 Page 1 of 1 509
EXPERIENCE VERIFICATION FOR A NEVADA REAL ESTATE LICENSE
FORM MUST BE COMPLETED BY VERIFYING BROKER, DEVELOPER OR BROKER-
SALESPERSON MANAGER
1. Name: License Number:
State of issuance:
2. Employment History: Full-time Part-time
3. Employment Dates: From to
From to
From to
Month / Day / Year Month / Day / Year
Multiple lines may be used for breaks in employment with same broker and company only.
4. Declaration: I, , say that in relation to the period of time listed
above, that the applicant named above held an active real estate license and was/is associated with the company named
; and that I am/was the duly licensed real estate
broker, registered developer or broker-salesperson manager for said company. Under penalty of perjury, I declare that
the foregoing is true and correct.
Name: License Number:
Signature:
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FORM MUST BE COMPLETED BY VERIFYING BROKER, DEVELOPER (Nevada Real Estate Division)

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Completed 28 December 2021

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