RE Rec Rev 9/19
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
License Services Division
450 Columbus Blvd, Ste. 801
Hartford, CT 06103
Email: dcp.licenseservices@ct.gov
Website: www.ct.gov/dcp
Legal Entity Designee to Individual Broker - Reinstatement
Section I: Legal Entity Information
Name of Legal Entity
Legal Entity License Number
1. Has the entity been officially dissolved with the CT Secretary of the State? YES NO If Yes, return the license certificate and
attach copy of official Certificate of Dissolution you received from the CT Secretary of State’s office.
Section II: Individual Broker Information
First Name Middle Initial Last Name
Street Address
City State Zip Code
Social Security Number
Date of Birth
Telephone Number
CT Individual Broker License #
Email Address to be used for all correspondence
1. Have you ever been convicted of a felony crime or been convicted of a crime including, but not limited to, forgery, embezzlement,
obtaining money under false pretenses, extortion, criminal conspiracy to defraud, or any like offenses?
YES NO If Yes, attach
a statement providing the date(s) and nature of conviction(s), where the cases were decided, and a description of the circumstances.
2. Have you had a real estate license refused, suspended, revoked or has a complaint been filed against you in any State? YES NO
If Yes, attach a statement providing the state(s) and the details regarding the type of action taken.
3. Do you agree to return immediately any license, when required by the CT Real Estate Commission, and to conform to all rules and
regulations promulgated by the Commission and this Department?
YES NO
Section III: Consent for Service - All Non CT Residents
I hereby file irrevocably consent that suits and actions may be commenced against such applicant in the proper court in any judicial
district of the state in which a cause of action may arise or in which the plaintiff may reside, and that in the event proper service of
process cannot be made upon such applicant in any such proceeding, service may be made by service of process or pleading authorized
by the laws of Connecticut on the Chairperson of the Connecticut Real Estate Commission, hereby stipulating and agreeing that such
service of such process or pleading upon the said Chairperson of the Connecticut Real Estate Commission shall be taken and held in all
courts to be as valid and binding as if service had been made upon said applicant in the State of Connecticut, in accordance with
Connecticut General Statutes, Section 20-317(b).
______________________________________________________________________________ ____________________________
Signature of Applicant Date
Section IV: Notarization – All Applicants
For Official Use Only
I, ______________________________________________________ being duly sworn according to law, hereby affirm that the answers
Printed Name of Applicant
given in this application are true to the best of my knowledge and belief and that this application is made for the sole purpose of obtaining
a Real Estate license.
________________________________________________________________________ __________________________
Signature of Applicant Date
Subscribed and sworn to before me, this _________ day of _____________________________ 20 _______
________________________________________________________________________ __________________________
Signature of Notary Public, Justice of the Peace, Commissioner of Superior Court My Commission Expires
