STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
e-mail: realest@red.nv.gov * http://red.nv.gov
12/18/2019 Page 3 of 4 659
3. CRIMINAL/BACKGROUND HISTORY
If you answer YES to any question listed below, you are required to attach the order of the court or agency which was
rendered as a result of the proceedings. On a separate sheet provide full details, including the administrative agency, court,
title of the proceeding, disposition and any other pertinent information. Attach all information to this application.
a. Have you or any business in which you are or were an owner, partner, officer or director ever been 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 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
d. Have you ever been convicted of a felony, gross misdemeanor, or misdemeanor? Yes No
e. 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
f. Are you presently on parole or probation or paying any restitution? Yes No
g. Have you ever filed bankruptcy or has bankruptcy been filed against you?
If yes, please provide the date of discharge:
If filed within the past 7 years, please provide a copy of the discharge.
Yes No
4. CHILD SUPPORT CHECK ONE BOX ONLY.
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 AM NOT 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.
5. DECLARATION: NRS 53.045
I hereby state under 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 license, certification or renewal of a license or certification will be denied.
I further certify that I will faithfully comply with all the statutes and regulations of the State of Nevada pertaining to the conduct of a
Community Manager in the State of Nevada.
I, by signing this application, authorize any person or institution to which reference is made by me in connection with the application
to release or divulge to the Real Estate Division any information in the possession of such person or institution regarding me.
Signature: Date: