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REAL ESTATE DIVISION REGISTRATION of an ASSET MANAGEMENT (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
e-mail: realest@red.nv.gov * http://red.nv.gov/
Revised 06/25/19 Page 1 of 4 Form 665A
REGISTRATION of an ASSET MANAGEMENT COMPANY PRINCIPAL
INSTRUCTIONS
If the Asset Management Company is:
• An individual person, the individual person must submit Form 665A;
• A partnership, each general partner must submit Form 665A;
• A corporation, each officer of the corporation must submit Form 665A; or
• An unincorporated association, each director or trustee must submit Form 665A.
The completed form(s) Form 665A must be submitted with the Asset Management Company Registration Form
665. Each applicant must submit with the completed Form 665A:
FINGERPRINT CARD: The applicant is required to submit fingerprints for a background investigation.
Applicants have two options by which to have their fingerprints taken:
A. By a Division authorized digital (electronic) vendor. The list of authorized electronic vendors may
be found on our web site on Form 619. Fees for processing are paid to the authorized vendor. A
Verification that fingerprints have been submitted will be provided by the vendor and must be
submitted with the application.
B. 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).
PHOTOGRAPH: Attach a 2” x 2” head shot picture taken within the past 12 months.
CONSENT TO SERVICE OF PROCESS: If you are not a resident of the State of Nevada you must
complete the Consent to Service of Process.
CIVIL APPLICANT WAIVER: Complete the Nevada Department of Public Safety waiver form attached
to this application.
IMPORTANT NOTES:
• All required fees must accompany application.
• Only original applications are accepted.
• The registration is valid when the Asset Management Company 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
e-mail: realest@red.nv.gov * http://red.nv.gov/
Revised 06/25/19 Page 2 of 4 Form 665A
REGISTRATION of an ASSET MANAGEMENT COMPANY PRINCIPAL
1.
APPLICANT:
Applicant name:
Position in asset
company:
General Partner Principal Manager Director Trustee
Officer (position or office held) _______________________________________
Residence address:
Email address:
Date of birth:
Social Security #:
Phone:
Cell:
2.
COMPANY INFORMATION: Location in which you will be conducting asset management services
as registered on Form 665-Main Office or Branch Office.
Company name:
Company address:
Phone:
Fax:
Email:
DIVISION USE ONLY: Date: ___________________ Receipt #_______________________ 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
e-mail: realest@red.nv.gov * http://red.nv.gov/
Revised 06/25/19 Page 3 of 4 Form 665A
3.
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.
Yes No
a.
Have you 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 other discipline
within the last ten (10) years?
b.
Have you had a license, certificate or registration issued pursuant to the provisions of this chapter
suspended, revoked, or voluntarily surrendered in lieu of other discipline within the last ten (10) years?
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?
d.
Have you ever been convicted of, or entered a plea of guilty or nolo contendere to, a felony relating to the
practice of real estate?
4. Regulation/Services The applicant attests that he/she has read and understands the provisions of sections 29.5 to 33,
Yes inclusive, of Senate Bill No. 314 of the 2011 Legislative Session.
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 Asset Management
Company individual application Form 665A 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
ss.
COUNTY OF
Signed and sworn to (or affirmed) before me on
Date, by
Seal
X
Signature of Notary
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
e-mail: realest@red.nv.gov * http://red.nv.gov/
Revised 06/25/19 Page 4 of 4 Form 665A
6.
Nevada Resident:
Yes No (if No, complete the following form)
CONSENT TO SERVICE OF PROCESS
Full legal name:
Hereinafter referred to as “Applicant,” hereby irrevocably constitutes and appoints the Administrator of the
Division of Real Estate, Department of Business & Industry, State of Nevada or his/her successor in office, to be
his/her true and lawful agent within this state, upon whom all legal process in any suit, action or proceeding
arising under, or in any way connected with any provisions of Chapter 645, 645C, 645D, 119, 119A, 119B, 116,
116A and 116B of Nevada Revised Statutes, or any rule or order pursuant thereto, or based upon any fraud,
deceit, breach of contract or other thing connected with the sale or offer for sale, negotiation, appraisal or
inspection of any real estate, timeshare or campground membership, may be served upon said applicant, personally
within the State of Nevada. Until the applicant attests by affidavit to the Administrator that he/she is a bona fide
resident of the State of Nevada, this appointment and the authority of said attorney shall continue in force and
effect so long as any such liability remains outstanding, and a copy of any process served hereunder may be sent
by certified mail, return receipt requested, addressed to:
Full legal address:_____________________________________________________________________
X
Signature of person presenting this document to the notary.
STATE OF:______________________
}ss
COUNTY OF: _____________________
This instrument was acknowledged before me on ___________ date, in the possession of applicant
(APPLICANT’S NAME) _______________________________________________________.
Print name of person signing this document
seal
X
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:
Nevada Real Estate Division
Address:
3300 West Sahara Avenue #350
Las Vegas, NV 89102
Agency Representative:
PLEASE PRINT
Last Name
First Name
Middle
Agency Representative Signature:
Date:
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Completed 28 December 2021

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