Fillable LICENSE HISTORY REQUEST (Utah DRE)

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LICENSE HISTORY REQUEST (Utah DRE)

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The LICENSE HISTORY REQUEST (Utah DRE) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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Rev. 8/08/2013
160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov • Email: realestate@utah.gov
State of Utah
Department of Commerce
Division of Real Estate
LICENSE HISTORY REQUEST
Complete, sign, and submit this form along with a $20 non-refundable fee to the Utah Division of
Real Estate by fax, email, mail, or in person at the address below.
** INCLUDE THE ADDRESS TO WHICH YOU WANT THE HISTORY SENT**
Name of Requestor: _______________________________________________________________________
License History for (name): ______________________________ License #:______________________
Phone: ____________________________ Email: ____________________________________________
Mailing Address: _________________________________________________________________________
Street
________________________________________________________________________________________
City State Zip
LICENSE TYPE: ( ) Appraiser ( ) Real Estate Agent ( ) Real Estate Broker
( ) Mortgage Loan Originator ( ) Mortgage Entity
License history includes:
Original Issue Date Expiration Date Current Status
Current Affiliation Exam History Disciplinary Actions
Additional information requested: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
( ) Check ( ) Visa ( ) MasterCard ( ) American Express
Make checks payable to: Utah Division of Real Estate
Card # __________________________________________ Expires ______________
Signature ________________________________________ CCV# ______________
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LICENSE HISTORY REQUEST (Utah DRE)

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Completed 14 February 2021

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