Fillable REAL ESTATE DIVISION APPLICATION for the INDIVIDUAL REGISTRATION (Nevada Real Estate Division)

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REAL ESTATE DIVISION APPLICATION for the INDIVIDUAL REGISTRATION (Nevada Real Estate Division)

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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 / (702) 486-4033
realest@red.nv.gov / http://red.nv.gov/
Revised 9/4/2020 Page 1 of 3 Form 571A
APPLICATION for the
INDIVIDUAL REGISTRATION of a PRINCIPAL, GENERAL PARTNER, DIRECTOR, OFFICER or
TRUSTEE of an APPRAISAL MANAGEMENT COMPANY
INSTRUCTIONS
Each Principal, General Partner, Director, Officer or Trustee of an applying Appraisal Management Company must
complete Form 571A and submit it with the Appraisal Management Company Registration Form 571. Each applicant
must submit with the completed Form 571A:
1. For each individual applicant attach one completed finger print card (form FD-258) printed by a Law Enforcement
Agency and attach a cashier’s check or money order (personal and company checks are NOT accepted by DPS)
separately for each applicant in the amount of $40.25, made payable to the Nevada Department of Public Safety
(DPS) or attach a Verification of fingerprints taken by an approved vendor (see Form 619).
2. Attach a 2” x 2” head shot picture taken within the past 12 months.
3. If you answered “yes” to any question, attach a dated and signed written explanation addressed to the Nevada Real
Estate Division and provide any other pertinent information such as a copy of the court proceedings and the final
judgment or conclusions of law and current disposition of the matter.
4. If you are not a resident of the State of Nevada, you must complete the Consent to Service of Process (Form 656).
IMPORTANT NOTES
• AMC means Appraisal Management Company.
• All required fees must accompany application.
• Only original applications are accepted.
• The registration is valid when the AMC receives the registration issued by the Nevada Real Estate Division. The
registration expires one year from the date of issuance.
• The application is a public record under Nevada Revised Statutes Chapter 239. Certain information is deemed by law
to be confidential. However, most information provided by an applicant is public information and must be provided
upon request to the Division.
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 / (702) 486-4033
realest@red.nv.gov / http://red.nv.gov/
Revised 9/4/2020 Page 2 of 3 Form 571A
APPLICATION for the
INDIVIDUAL REGISTRATION of an OFFICER, PRINCIPAL, GENERAL PARTNER, DIRECTOR
or TRUSTEE of an APPRAISAL MANAGEMENT COMPANY
1. APPLICANT
Applicant Name:
Position in AMC: General Partner Principal Manager Director Trustee
Officer (type) Other (type)
Residence Address:
City: State: Zip Code:
Mailing Address (if applicable):
City: State: Zip Code:
Last 4 of Social Security Number or Federal Tax ID: Date of Birth:
Phone Number: Cell Phone: Email Address:
2. COMPANY INFORMATION: Location in which you will be conducting appraisal services as registered on Form
571 (Main Office) or 571B (Branch Office).
Company Name:
Company Address:
City: State: Zip Code:
Phone Number: Fax Number: Email Address:
3. NEVADA RESIDENT? Yes No
If NO, complete the Consent to Service of Process, Form 656.
DIVISION USE ONLY
Date: Receipt Number: Processor Initials:
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 / (702) 486-4033
realest@red.nv.gov / http://red.nv.gov/
Revised 9/4/2020 Page 3 of 3 Form 571A
4. CRIMINAL/BACKGROUND HISTORY: If your answer is YES to any of the following questions, attach the order
as a result of the proceedings. On an attached sheet, give full details including the administrative agency, court, and
title of the proceeding, disposition, and any other pertinent information.
a. Have you ever had a professional or occupational license issued by any state, district or territory of the
United States or any foreign country suspended, revoked, or voluntarily surrendered in lieu of
suspension or revocation which has not been subsequently reinstated?
Yes No
b. Have you ever had a license, certificate or registration issued pursuant to the provisions of this chapter
suspended, revoked, or voluntarily surrendered in lieu of suspension or revocation which has not been
reinstated?
Yes No
c. Have you ever been convicted of, or entered a plea of guilty or nolo contendere to, a felony or any
crime involving fraud, misrepresentation or moral turpitude?
Yes No
d. Have you ever been convicted of, or entered a plea of guilty or nolo contendere to, a felony relating to
the practice of appraisal or real estate?
Yes No
5. CHILD SUPPORT DECLARATION (NRS 425.520)
Please indicate in the appropriate box below which one of the provisions apply to you. Your application for the
issuance of this license will be denied if you do not complete this section.
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 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.
6. ACKNOWLEDGEMENT
I hereby certify under penalty of perjury that the answers contained in this AMC individual application Form 571A
are true and correct. 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 a plan, my application for license, certification or renewal of a license or certification
will be denied.
Print Name: Signature:
Verification upon oath:
STATE OF:
COUNTY OF:
} ss.
Signed and sworn to (or affirmed) before me on (date) by .
Seal Signature of Notary:
0505RCCD-003(07/2017rev)
Fingerprint Background Waiver Page 1 of 2
Fingerprint Background Waiver
As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based
criminal history record check for a noncriminal justice purpose you have certain rights which are
discussed below.
1. You must be notified by the Nevada Real Estate Division (name of requesting agency)
that your fingerprints will be used to check the criminal history records of the FBI and the
State of Nevada.
2. If you have a criminal history record, the officials making a determination of your suitability
for the job, license or other benefit for which you are applying must provide you the
opportunity to complete or challenge the accuracy of the information in the record. You may
review and challenge the accuracy of any and all criminal history records which are returned
to the submitting agency. The proper forms and procedures will be furnished to you by the
Nevada Department of Public Safety, Records Bureau upon request. If you decide to challenge
the accuracy or completeness of you FBI criminal history record, Title 28 of the Code of
Federal Regulations Section 16.34 provides for the proper procedure to do so:
16.34 - Procedure to obtain change, correction or updating of identification
records. If, after reviewing his/her identification record, the subject thereof
believes that it is incorrect or incomplete in any respect and wishes changes,
corrections or updating of the alleged deficiency, he/she should make application
directly to the agency which contributed the questioned information. The subject of
a record may also direct his/her challenge as to the accuracy or completeness of any
entry on his/her record to the FBI, Criminal Justice Information Services (CJIS)
Division ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306.
The FBI will then forward the challenge to the agency which submitted the data
requesting that agency to verify or correct the challenged entry. Upon the receipt of
an official communication directly from the agency which contributed the original
information, the FBI CJIS Division will make any changes necessary in accordance
with the information supplied by that agency.
3. Based on 28 CFR § 50.12 (b), officials making such determinations should not deny the
license or employment based on information in the record until the applicant has been
afforded a reasonable time to correct or complete the record or has declined to do so.
4. You have the right to expect that officials receiving the results of the fingerprint-based
criminal history record check will use it only for authorized purposes and will not retain or
disseminate it in violation of federal or state statute, regulation or executive order, or rule,
procedure or standard established by the National Crime Prevention and Privacy Compact
Council.
0505RCCD-003(07/2017rev)
Fingerprint Background Waiver Page 2 of 2
5. I hereby authorize the Nevada Real Estate Division (name of requesting agency)
(name of requesting agency), to submit a set of my fingerprints to the Nevada Department
Public Safety, Records Bureau for the purpose of accessing and reviewing State of Nevada
and FBI criminal history records that may pertain to me.
In giving this authorization, I expressly understand that the records may include information
pertaining to notations of arrest, detainments, indictments, information or other charges for
which the final court disposition is pending or is unknown to the above referenced agency.
For records containing final court disposition information, I understand that the release may
include information pertaining to dismissals, acquittals, convictions, sentences, correctional
supervision information and information concerning the status of my parole or probation
when applicable.
6. I hereby release from liability and promise to hold harmless under any and all causes of legal
action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my
criminal history records search and provided information to the submitting agency for any
statement(s), omission(s), or infringement(s) upon my current legal rights. I further release
and promise to hold harmless and covenant not to sue any persons, firms, institutions or
agencies providing such information to the State of Nevada on the basis of their disclosures. I
have signed this release voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar
process, shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature
voluntarily appears below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEASE PRINT
Last Name
First Name
Middle
ADDRESS:
PLEASE PRINT
Applicant’s Signature:
Date:
Submitting Agency:
Address:
Agency Representative:
PLEASE PRINT
Last Name
First Name
Middle
Agency Representative Signature:
Date:
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REAL ESTATE DIVISION APPLICATION for the INDIVIDUAL REGISTRATION (Nevada Real Estate Division)

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Completed 28 December 2021

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