Fillable GENERAL INFORMATION 1. NAME OF APPLICANT (LAST, FIRST (California Department of Real Estate)

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GENERAL INFORMATION 1. NAME OF APPLICANT (LAST, FIRST (California Department of Real Estate)

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GENERAL INFORMATION




IDENTIFICATION NUMBER EFFECTIVE DATE EXPIRATION DATE VIOLATION
PRINTS SENT COPY TO PRLS CONTRACT REVIEWER PROCESSOR’S NUMBER COMMENTS
DRE USE ONLY
1. NAME OF APPLICANT (LAST, FIRST & MIDDLE)
2. MAILING ADDRESS (STREET ADDRESS, CITY, STATE, ZIP CODE)
3. DO YOU RESIDE IN CALIFORNIA?
YES NO IF NO, A CONSENT TO SERVICE OF PROCESS (RE 263) MUST BE ON FILE WITH DRE.
4. BUSINESS TELEPHONE 5. RESIDENCE TELEPHONE 6. SOCIAL SECURITY NO.(see Privacy Notice) 7. BIRTH DATE
8. HAVE YOU USED ANY OTHER NAMES (I.E., MAIDEN, AKA, ETC.)?
YES NO IF YES, LIST NAME(S) USED.
9. GENDER 10A. HAVE YOU PREVIOUSLY HELD A REAL ESTATE LICENSE IN ANY STATE, INCLUDING CALIFORNIA?
M F YES NO IF YES, COMPLETE 10B – 10D.
10B. TYPE OF LICENSE 10C. EFFECTIVE DATE 10D. IDENTIFICATION NUMBER
11A. HAVE YOU EVER BEEN A PRLS DESIGNATED AGENT?
YES NO IF YES, COMPLETE 11B – 11C.
11B. NAME OF INDIVIDUAL LICENSEE OR CORPORATION 11C. DATES EMPLOYED (FROM—TO)


Page 2 of 3RE 256
DESIGNATED AGENT CERTIFICATION
I certify under penalty of perjury that the answers and statements given in this application are true and correct.
18. SIGNATURE OF APPLICANT 19. DATE
@
BACKGROUND INFORMATION
Carefully read and provide detailed and accurate answers to questions 12-15 below. You must provide a "yes" or "no" response to all questions, Attach additional sheets if
you need more space. Each additional sheet must be sign by applicant. Failure to disclose pertinent information may result in denial of your license application and/or delays.
12. HAVE YOU EVER HAD A DENIED, SUSPENDED, RESTRICTED OR REVOKED BUSINESS OR PROFESSIONAL
LICENSE (INCLUDING REAL ESTATE), CERTIFICATE OR PERMIT, IN CALIFORNIA, OR ANY OTHER STATE OR
FEDERAL LAW? IF YES, COMPLETE ITEM 16.................................................................................................................. YES NO
13. ARE THERE ANY DISCIPLINARY ACTIONS PENDING AGAINST A BUSINESS, PROFESSIONAL OR OCCUPA-
TIONAL LICENSE, CERTIFICATE, OR PERMIT YOU HOLD AT THIS TIME? IF YES, COMPLETE ITEM 16............... YES NO
14. HAVE YOU EVER BEEN REQUIRED TO REGISTER AS A SEX OFFENDER PURSUANT TO THE PROVISIONS
OF SECTION 290 OF THE CALIFORNIA PENAL CODE OR ANY COMPARABLE LAW OF ANY STATE OR
GOVERNMENTAL UNIT? IF YES, COMPLETE ITEM 17.................................................................................................... YES NO
15. HAVE YOU EVER BEEN ORDERED TO CEASE DESIST AND/OR REFRAIN FROM DOING AN ACT(S), OR FROM
VIOLATING A LAW, RULE OR REGULATION BY, OR CITED FOR A BREACH OF ETHICS OR UNPROFESSIONAL
CONDUCT BY AN ADMINISTRATIVE AGENCY OR PROFESSIONAL ASSOCIATION IN CALIFORNIA OR ANY
OTHER STATE? IF YES, COMPLETE ITEM 16-17.............................................................................................................. YES NO
16. DETAILED EXPLANATION OF ITEM 12, 13, AND/OR 15.
16A. TYPE OF LICENSE 16B. LICENSE ID NO. 16C. LICENSE EXPIRATION DATE 16D. STATE
16E. ACTION (revoked, etc.) 16F. DATE OF ACTION 16G. DATE ACTION TERMINATED 16H. CODE SECTION VIOLATED
17. ADDITIONAL INFORMATION: SPECIFY WHICH LINES YOU ARE REFERRING TO. (ATTACH EXTRA SHEETS IF MORE ROOM IS NEEDED. EACH
ADDITIONAL SHEET MUST BE SIGNED BY APPLICANT.
Page 3 of 3RE 256
READ AND RETAIN FOR FUTURE REFERENCE
Fees





Fingerprint Services (Contact the facility for fees and hours)
       

         
www.ag.ca.gov 
           

Out-of-State Applicants




877-373-4542

   

Mailing Information
 



General Information
 
       Penciled applications will be
returned.
 
 
        

 

          


Designated Agent Information
        



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          


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        



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


          




       

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 
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

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   
        
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  
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         
        
         





   

          



          




         
        
       
       
       

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GENERAL INFORMATION 1. NAME OF APPLICANT (LAST, FIRST (California Department of Real Estate)

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Completed 28 December 2021

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