Fillable PRLS CORPORATION INFORMATION (California Department of Real Estate)

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PRLS CORPORATION INFORMATION (California Department of Real Estate)

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The PRLS CORPORATION INFORMATION (California Department of Real Estate) form is 4 pages long and contains:

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  • 46 check-boxes
  • 61 other fields

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1. CORPORATION NAME (ENTER AS SHOWN ON CERTIFICATE OF STATUS.)
2. FICTITIOUS BUSINESS NAME – IF ANY (ATTACH CERTIFIED COPY OF FICTITIOUS BUSINESS NAME STATEMENT.)
3A. CORPORATION’S MAILING ADDRESS — STREET ADDRESS OR POST OFFICE BOX
3B. CITY 3C. STATE 3D. ZIP CODE
4A. CORPORATION’S MAIN OFFICE ADDRESS — STREET ADDRESS
4B. CITY 4C. STATE 4D. ZIP CODE
5. NAME OF DESIGNATED AGENT FOR THIS LOCATION RE 256 ON FILE ID# — DRE USE ONLY
RE 256 ATTACHED
6A. IS THIS CORPORATION NOW OR HAS IT BEEN LICENSED TO PERFORM REAL ESTATE ACTIVITIES IN CALIFORNIA? 6B. IDENTIFICATION NUMBER
YES NO IF YES, COMPLETE 6B–6D.
6C. NAME OF REAL ESTATE CORPORATION 6D. EFFECTIVE DATE
PRLS CORPORATION INFORMATION
Read page 3 before completing this application. Type or print clearly in ink.
DRE USE ONLY
BOND APPROVAL BOND NUMBER
IDENTIFICATION NUMBER CONTRACT APPROVED
EFFECTIVE DATE EXPIRATION DATE
DATE MAILED
PROCESSOR’S # COMMENTS
7. NAME OF DESIGNATED OFFICER (CORPORATION OFFICER TO REPRESENT CORPORATION)
8A. MAILING ADDRESS — STREET ADDRESS OR POST OFFICE BOX
8B. CITY 8C. STATE 8D. ZIP CODE
9. DO YOU RESIDE IN CALIFORNIA?
YES NO IF NO, A CONSENT TO SERVICE OF PROCESS (RE 263) MUST BE ON FILE WITH DRE.
10. RESIDENCE TELEPHONE NUMBER 11. BUSINESS TELEPHONE NUMBER 12. SOCIAL SECURITY OR INDIVIDUAL TAXPAYER ID NUMBER 13. BIRTH DATE
14A. WHAT IS YOUR STATUS WITH THE CORPORATION? (CHECK ONE) 14B. IF SHAREHOLDER, WHAT % OF SHARES ARE OWNED?
OFFICER DIRECTOR SHAREHOLDER
15. HAVE YOU USED ANY OTHER NAMES (I.E., MAIDEN, AKA, ETC.)?
YES NO IF YES, LIST NAME(S) USED:
16A. DO YOU HOLD OR HAVE YOU PREVIOUSLY HELD A REAL ESTATE LICENSE IN CALIFORNIA?
YES NO IF YES, COMPLETE 16B –16D.
16B. ID# 16C. EFFECTIVE DATE 16D. EXPIRATION DATE
17. LIST THE NAMES AND TITLES OF ALL OFFICERS, DIRECTORS OR SHAREHOLDERS OWNING 25% OR MORE OF THE CORPORATE STOCK.
PRLS OFFICER INFORMATION
COPY TO PRLS CONTRACT
REVIEWER




RE 272 Page 2 of 3
APPLICANT CERTIFICATION
I certify under penalty of perjury under the laws of the State of California that the foregoing answers and statements given in this application are true and correct,
that at the time of license issuance I will be 18 years of age or older, that if licensed I will not violate any provisions of the Real Estate Law nor abuse the privileges
of a Prepaid Rental Listing Service licensee. I understand that the Department of Real Estate cannot refund or transfer the fees submitted with this application if I
fail to qualify for the license for any reason or withdraw this application. I understand that it is my obligation to notify the Department upon licensure within 30 days
in writing or by ling form RE 238 of any conviction, criminal complaint, information or indictment charging a felony, or disciplinary action taken by another licensing
entity or authority of this state or an agency of the federal government pursuant to Business and Professions Code Section 10186.2
24. SIGNATURE OF APPLICANT (MUST BE ORIGINAL SIGNATURE) 25. DATE
@
BACKGROUND INFORMATION
Carefully read and provide detailed and accurate answers to questions 18-21 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.
18. HAVE YOU EVER HAD A DENIED, SUSPENDED, RESTRICTED OR REVOKED BUSINESS OR PROFESSIONAL
LICENSE (INCLUDING REAL ESTATE), IN CALIFORNIA, OR ANY OTHER STATE? IF YES, COMPLETE ITEM 22.........
YES NO
19. ARE THERE ANY DISCIPLINARY ACTIONS PENDING AGAINST A BUSINESS OR PROFESSIONAL LICENSE YOU
HOLD AT THIS TIME? IF YES, COMPLETE ITEM 22..................................................................................................................
YES NO
20. 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 23............................................................................................................ YES NO
21. 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 22 AND 23............................................................................................................................ YES NO
22. DETAILED EXPLANATION OF ITEM 18, 19, AND/OR 21. IF NEEDED EXPLANATION MAY BE PROVIDED IN ITEM 23.
22A. TYPE OF LICENSE 22B. LICENSE ID NO. 22C. LICENSE EXPIRATION DATE 22D. STATE
22E. ACTION (revoked, etc.) 22F. DATE OF ACTION 22G. DATE ACTION TERMINATED 22H. CODE SECTION VIOLATED
23. 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.
RE 272 Page 3 of 3



Fingerprint Fees
          


       

Fingerprint Services (Contact the facility for fees and hours)



www.ag.ca.gov

Out-of-State Applicants
 

        

877-373-4542



License Application Fees
Refer to form RE 254 PRLS License Information for
information on fees.
Mailing Information
Submit the following documents before the license expiration date:
PRLS license application
License application fee
If appropriate, submit rider to bond, Additional Location Application
(RE 274)
Make check or money order payable to:
Department of Real Estate
Mail to: 


General Information
 
 Penciled applications will be returned.
 
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 
        
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 




Who must complete this application?
         
  licensed designated ocer

         

    

       

Completion Information
           

 
 


Fingerprint Requirement




Completion & Submission of Live Scan Service Request
(RE 237)



READ AND RETAIN FOR FUTURE REFERENCE


       


 
 
 






 
         


  


         
        
          





         

          



          




         
        
       
       
       

GENERAL INFORMATION
The Department of Real Estate is required to collect demographic information regarding applicants for licensure pursuant to Business
& Professions Code 480 et seq., if the applicant chooses to provide this information. Providing this information is voluntary, and
providing responses will not impact the Department’s review of your license application.
GENDER:
ETHNIC IDENTITY:
ASIAN PACIFIC ISLANDER
BLACK OR AFRICAN AMERICAN
AMERICAN INDIAN OR ALASKA NATIVE
HISPANIC OR LATINO (ALONE OR IN
COMBINATION WITH ANY OTHER RACE)
WHITE
MULTIPLE RACES*
I CHOOSE NOT TO IDENTIFY
MULTIPLE ASIAN**
INDIAN
CAMBODIAN
CHINESE
FILIPINO
JAPANESE
KOREAN
LAOTIAN
VIETNAMESE
OTHER ASIAN
MULTIPLE PACIFIC ISLANDER***
GUAMANIAN
HAWAIIAN
SAMOAN
OTHER PACIFIC ISLANDER
* If you identify with more than one race that is Non-Hispanic or Latino, select Multiple Races.
** If you identify with more than one Asian ethnicity, select Multiple Asian
*** If you identify with more than one Pacic Islander ethnicity, select Multiple Pacic Islander
State of California
Department of Real Estate
License Application Demographic Survey
RE 243 (Rev. 7/20)
Male Female Non-binary
Thank You For Completing This Questionnaire
I choose not to identify
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PRLS CORPORATION INFORMATION (California Department of Real Estate)

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Completed 28 December 2021

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