COMMISSION USE ONLY
Receipt # ______________
Date Paid ______________
ARKANSAS REAL ESTATE COMMISSION
Phone: (501) 683-8010 Fax: (501) 683-8020
REAL ESTATE INSTRUCTOR SCHOOL
AFFILIATION FORM
AREC 4/2014
Return to: Arkansas Real Estate Commission | 612 South Summit St | Little Rock, AR 72201
Licensee’s Name (Printed) : ______________________________________________________________
Licensee’s Signature: ___________________________________________ Date: __________________
(First Name) (Middle Name) (Last Name)
School Name: _______________________________________ School Phone: ___________________
Address: ____________________________________________ PO Box: ____________
Fax: ________________________________ Email address: _______________________________
Home Address: ____________________________________________ PO Box: ____________
Personal Phone: _______________________ Email address: __________________________________
City: __________________________________ State: __________ Zip: _____________
City: __________________________________ State: __________ Zip: _____________
SCHOOL INFORMATION:
is form is to be completed for each school that an instructor teaches with other than their primary school.
As Principal Instructor, I hereby authorize this instructor to teach courses with the above school.
Main School
Branch School
Instructor License Number: _________________________
Instructor License Number: _________________________
Principal Instructor Name (Please Print)
Principal Instructor Signature Date
_______________________________________
________________________________________________________
