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REAL ESTATE DIVISION STATE OF NEVADA DEPARTMENT OF (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 6/25/2019 Page 1 of 7 Form 542
NEVADA OUT-OF-STATE COOPERATIVE CERTIFICATE
CHECKLIST AND APPLICATION
Cooperative Certificates are for A SINGLE TRANSACTION ONLY and NOT MEANT for conducting
general real estate business on a day-to-day basis. Certificate expires at the end of the month after one year from
the issuance date. The certificate is non-renewable. You must submit a new application
FEE: Certificate fee accepted in certified funds only made payable to the Nevada Real Estate Division for $150.00.
ATTACHED LICENSE(S): Copy of current active Broker’s and Salesperson’s license if applicable.
HISTORY: A current certified license history for active Broker’s and Salesperson’s license if applicable.
FINGERPRINTS: One finger print card taken by a law enforcement agency and fee in the form of certified funds, made payable
to the Department of Public Safety for $40.25. OR submit the approved finger print vendor verification form (see vendor list form
#619) for active Broker and Salesperson if applicable.
PHOTOGRAPH: Attach to page #7 a 2X2 inch photograph for each out-of-state applicant.
CIVIL APPLICANT WAIVER: Complete the Nevada Department of Public Safety waiver form attached to the out-of-state
cooperative certificate application.
CLIENT AND PROPERTY INFORMATION: Attach identifying documentation.
Please complete this application as follows:
• OUT-OF-STATE BROKER: section I: pages 1-3 and page 7.
• NEVADA BROKER: section II, pages 4 & 5.
• OUT-OF-STATE SALESPERSON: page 6 and page 7
Section I. Must be completed by the OUT-OF-STATE BROKER
Please print or type.
1.
APPLICANT: Out-of-State Broker Individual’s name.
Name:______________________________________________________________________
Home address: _______________________________________________________________
Mailing Address (if applicable): _________________________________________________
Home Phone: ________________________ Cellular: _________________________
E-mail address: ____________________________________________
Date of birth: __________________ Social Security: _____________________
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 6/25/2019 Page 2 of 7 Form 542
2.
COMPANY: As registered with your regulatory agency: Company’s name
Company Name: _________________________________________________________________
Company Address: ________________________________________________________________
Mailing Address (if applicable): _____________________________________________________
E-mail address: _____________________________________________________
Bus Phone: ________________________ Fax#:________________________
3.
NEVADA BROKER: Name and business name and address of Nevada broker:
Broker name:__________________________________________________________________________
Business name: ________________________________________________________________________
4.
OTHER LICENSES
Yes No
Yes No
b. Have you ever been issued any type of professional license other than real estate by a state
agency or public authority in your state or in any other state?
Yes No
c. Do you have any current cooperative agreements with other Nevada brokers? If “yes”, please
provide your certificate number: COOP.__________
5.
COMPLETE THE FOLLOWING [a-e (1-6)]:
If your answer to any of the below is YES attach the order of the court or agency which was rendered as a result of the
proceedings. Give full details, including the administrative agency, court, title of the proceeding, disposition and any
other pertinent information on an attached sheet.
a)
Yes No
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?
b)
Yes No
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?
c)
Yes No
Have you ever filed bankruptcy or has bankruptcy been filed against you? If filed within 7 years
from the date of this application, please provide a copy of the discharge. Date of
discharge_________.
d)
Yes No
Are you presently on parole or probation or paying any restitution?
e)
Yes No
Have you ever been convicted of a felony or misdemeanor?
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 6/25/2019 Page 3 of 7 Form 542
6. 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. NRS 645.358
PLEASE 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 the
amount owed in that order.
7. APPLICANT DECLARATION: Signature of applicant-NRS 53.045
Applicant, by signing and filing this application, authorizes any person or institution to whom reference is made by the applicant 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 said
applicant.
The applicant does hereby certify that should a change of address occur, he will immediately notify the Real Estate Division, and that in the
event this certificate is canceled, suspended, or revoked he will promptly return same along with the identification card, to the Real Estate Division.
OUT-OF-STATE BROKER AFFIDAVIT
I,
being first duly sworn on oath, state that I have
personally prepared the foregoing application, that in acting as a cooperating broker, I agree to be bound by and subject to the
provisions found in Nevada Revised Statutes, Chapter 645, and the Regulations promulgated pursuant thereto, which I have read, and
that the statements made by me in this application are true and are made under the penalties of perjury.
X
Signature of Out-of-State Broker Applicant
State of
ss. County of
This instrument was acknowledged before me on _____________ (date) by _____________________________________________
(Print name of person who presents the document)
X
Date
Signature of Notarial Officer
My Commission Expires:
(Seal)
• 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.
• 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;
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 6/25/2019 Page 4 of 7 Form 542
NEVADA REAL ESTATE LICENSED BROKER
SECTION II ⎯ Must be completed by the Nevada Broker.
Please print or type:
1.
Name
First
Middle
Last
2.
Business Name:
Telephone No.
3.
Business Address:
No. and Street
City, State
Postal code
4.
Nevada License Number
______________________________
5.
Name of Out-Of-State Licensed Broker:
CORP LLC SOLE PROPRIETOR OTHER________________
a. Name:
First
Middle
Last
b.
Business Address:
No. and Street
City, State
Postal code
c.
Business Name:
_________________________
Contact phone #:
( ) _________________
6.
Yes No Has any legal proceeding, civil or criminal, in which you were named as a party been
initiated at any time since the filing of your last application for a license?
If “yes,” give full details, including the court, title of proceeding and disposition on an attached sheet.
7.
List names of all real estate brokers and salesmen associated with you or in your employ that, in your
absence, will be authorized to act as your representative with the out-of-state licensed broker. Complete the
Nevada Broker portion of the Authorization for Out-of-State Salesperson form.
NAME
STATUS
LICENSE NUMBER
8.
List all cooperative agreements you currently have with brokers of other states.
Furnish name(s), certificate number(s), address(es) and date(s) of issuance.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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 6/25/2019 Page 5 of 7 Form 542
NEVADA BROKER AFFIDAVIT
I,
being first duly sworn on oath, state that I
am the Nevada Broker of Record. In acting as a cooperating broker, I agree to be bound by and subject to the provisions found in
Nevada Revised Statutes, Chapter 645, and the Regulations promulgated pursuant thereto, which I have read, and that the statements
made by me in this application are true and are made under the penalties of perjury.
x
Signature of Nevada Broker
State of
ss. County of
This instrument was acknowledged before me on ___________ (date) by ______________________________
(Print name of person who presents the document)
x
Date
Signature of Notarial Officer
(seal)
My Commission Expires
Revised 6/25/2019 Page 6 of 7 Form 542
STATE OF NEVADA
REAL ESTATE DIVISION
AUTHORIZATION FOR OUT-OF-STATE SALESPERSON
1. Complete this form only when an out-of-state salesperson is conducting Nevada real estate business.
The out-of-state Salesperson must carry this authorization at all times.
NEVADA BROKER
Name:
Business name:
X______________________________________
Bus address: __________________________________
SHARATH CHANDRA, ADMINISTRATOR
Department of Business and Industry
Nevada Real Estate Division
X
(Signature)
License #: _____________________________
Official with raised seal
OUT-OF-STATE BROKER
OUT-OF-STATE SALESPERSON
Name
Name:
Business Name:
Business Name:
Bus address:
Bus address:
X
X
(Signature)
(Signature)
License #: _______________________________
License #: _______________________________
INSTRUCTIONS AND GIDELINES FOR THE APPLICANT OF A
NEVADA COOPERATIVE BROKER CERTIFICATION:
For Division Use Only
Issuance Date: _______________________ Expiration Date: ________________________________
(Expires 12 months from date of issuance.)
Certificate #: _________________________
For Division Use Only
Issuance Date: ______________________ Expiration Date: ______________________
(expires 6 months from date of issuance)
Certificate #: _______________________
Revised 6/25/2019 Page 7 of 7 Form 542
VITAL STATISTICS
FILL OUT THE VITAL STATISTICS BELOW –Print or Type
Name:
Residence Address:
Email address:
Phone contact #:
Social Security Number:
Date of Birth:
Place of Birth:
Citizenship:
Signature:
Date:
REPORT OF EXISTENCE OF NEVADA BUSINESS LICENSE
Pursuant to NRS 645
All applicants MUST complete this section. Please select ONE option.
I have a Nevada business license number assigned by the Nevada Secretary of State upon compliance with the provisions of NRS Chapter
76.
My Nevada business license number is: _______________________________________
I have applied for a Nevada business license with the Nevada Secretary of State upon compliance with the provision of NRS Chapter 76
and my application is pending.
I do NOT have a Nevada business license number.
The Real Estate Division is not the arbiter of determining whether the applicant needs a business license. Information about the Nevada business
license can be found on the Secretary of State’s website at: http://nvsos.gov/
PHOTOGRAPH
Under authority granted by the Regulations, NAC 645.180,1(f), each applicant for an original out-of-state cooperative certificate will
be required to submit a photograph of himself as part of the application when filed. Attach your photo to this page.
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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