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 12/07/2020 Page 4 of 6 Form 549
4. PERSONAL 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 (see NRS 645.330).
a. Have you or any business in which you are or were an owner, partner, officer or director ever been involved
in an administrative proceeding regarding any professional or occupational license?
Yes No
b. Has any license issued to you or any partnership or corporation of which you were a member or officer by
any public authority been suspended or revoked?
Yes No
c. Has a surety company declined to be surety on any bond written on you in the two years prior to the date of
the application?
Yes No
d. Have you ever been convicted of a felony, gross misdemeanor, or misdemeanor? Yes No
e. Have you ever been convicted of, or are you under indictment for, or have you entered a plea of guilty or
nolo contendere to forgery, embezzlement, obtaining money under false pretenses, larceny, extortion,
conspiracy to defraud or any crime involving moral turpitude?
Yes No
f. Are you presently on parole or probation or paying any restitution? Yes No
g. Have you ever filed bankruptcy or has bankruptcy been filed against you? If yes, please provide the date of
discharge:
If filed within the past 7 years, please provide a copy of the discharge.
Yes No
5. CHILD SUPPORT QUESTIONNAIRE: YOU ARE REQUIRED TO CHECK ONE BOX.
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 that
amount owed in that order.
6. NEVADA RESIDENT? Yes No
If no, complete and attach a notarized Consent to Service of Process, Form 656.
7. DECLARATION: Signature of Applicant
I, (print name) , hereby, under penalty of perjury, declare that the answers
contained in this application are true and correct; and 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 plan
my application for license, certification or renewal of a license or certification will be denied;
• That I will faithfully comply with all the statutes and regulations of the State of Nevada pertaining to the conduct of real
estate licensees in the State of Nevada;
• That by signing this application I authorize any person or institution to which reference is made by me in connection with the
application to release or divulge to the Real Estate Division any information in the possession of such person or institution
regarding me.
Signature: Date: