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1. CORPORATION NAME
2. NAME OF APPLICANT (LAST, FIRST & MIDDLE)
3A. MAILING ADDRESS — STREET ADDRESS OR POST OFFICE BOX
3B. CITY 3C. STATE 3D. ZIP CODE
4. DO YOU RESIDE IN CALIFORNIA?
YES NO IF NO, A CONSENT TO SERVICE OF PROCESS (RE 263) MUST BE ON FILE WITH DRE.
5. BUSINESS TELEPHONE 6 RESIDENCE TELEPHONE 7. SOCIAL SECURITY OR INDIVIDUAL TAXPAYER ID NUMBER 8. BIRTH DATE
9A. WHAT IS YOUR STATUS WITH THE CORPORATION? 9B. IF SHAREHOLDER IS MARKED YES, LIST PERCENTAGE OF SHARES OWNED.
OFFICER DIRECTOR SHAREHOLDER
10. HAVE YOU USED ANY OTHER NAMES (I.E., MAIDEN, AKA, ETC.)?
YES NO IF YES, LIST NAME(S) USED.
11. GENDER 12A. HAVE YOU PREVIOUSLY HELD A REAL ESTATE LICENSE IN CALIFORNIA?
M F YES NO IF YES, COMPLETE 12B–12D.
12B. TYPE OF LICENSE 12C. EFFECTIVE DATE 12D. IDENTIFICATION NUMBER
13A. HAVE YOU EVER BEEN A PRLS AGENT?
YES NO IF YES, COMPLETE 13B–13C.
13B. NAME OF INDIVIDUAL LICENSEE OR CORPORATION 13C. DATES EMPLOYED
14. HAS THERE BEEN A CHANGE OF UNLICENSED OFFICERS, DIRECTORS OR SHAREHOLDERS OWNING 25% OR MORE OF THE CORPORATE STOCK DURING THE LAST 4 YEARS?
YES NO IF YES, PROVIDE THE NAMES AND TITLES.
GENERAL INFORMATION
QUESTIONNAIRE
Please read information on page 3 before completing this application.
Type or print clearly in ink.
DRE USE ONLY
IDENTIFICATION NUMBER EFFECTIVE DATE EXPIRATION DATE DATE LICENSE SENT
VIOLATION PRINTS SENT COPY TO PRLS CONTRACT REVIEWER PROCESSOR’S NUMBER




RE 273 Page 2 of 3
UNLICENSED OFFICER CERTIFICATION
UnlicensedOcer/Director/Shareholder—Icertifyunderpenaltyofperjurythattheanswersandstatementsgiveninthisapplicationaretrueand
correct.
21. SIGNATUREOFUNLICENSEDOFFICER/DIRECTOR/SHAREHOLDER(MUSTBEORIGINALSIGNATURE.)22.DATE
@
BACKGROUND INFORMATION
Carefully read and provide detailed and accurate answers to questions 15-18 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.
15. 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 19.........
YES NO
16. ARE THERE ANY DISCIPLINARY ACTIONS PENDING AGAINST A BUSINESS OR PROFESSIONAL LICENSE YOU
HOLD AT THIS TIME? IF YES, COMPLETE ITEM 19.................................................................................................................. YES NO
17. 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 20............................................................................................................ YES NO
18. 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 19 AND 20............................................................................................................................ YES NO
19. DETAILED EXPLANATION OF ITEM 15, 16, AND/OR 18. IF NEEDED, EXPLANATION MAY BE PROVIDED IN ITEM 20.
19A. TYPE OF LICENSE 19B. LICENSE ID NO. 19C. LICENSE EXPIRATION DATE 19D. STATE
19E. ACTION (revoked,etc.) 19F. DATE OF ACTION 19G. DATE ACTION TERMINATED 19H. CODE SECTION VIOLATED
20. 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 273 Page 3 of 3
READ AND RETAIN FOR FUTURE REFERENCE
Completion & Submission of Live Scan Service
Request (RE 237)


the last part of the form.
     

completed original license application for the corporation and the
appropriate license fee.
Fingerprint Fees
         




Fingerprint Services (Contact the facility for fees and hours)
       

         
www.ag.ca.gov. Please note
           

Out-of-State Applicants




877-373-4542



Mailing Information
Mail To: 



General Information
 
• Type or print clearly in ink. Penciled applications will be returned.
 
 

identifying a mailing address.
 

      


Who must complete this application?
    

.

      
licensed designated ocer of the corporation.


Completion Information
           

 
•        

in processing this application.
Fingerprint Requirement


        
  
 

        




       


 
 
 


information.



  
         


   


         
        
          



for inspection.

         

          


an application for a license.
          




This information may be transferred to real estate licensing agencies
        
       
       
       

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Completed 28 December 2021

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