Fillable REAL ESTATE RECIPROCITY APPLICATION *RECIPROCITY EXISTS WITH GEORGIA, (Utah DRE)

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REAL ESTATE RECIPROCITY APPLICATION *RECIPROCITY EXISTS WITH GEORGIA, (Utah DRE)

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  • 43 check-boxes
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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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Rev. 0
6/03/2020
Page 1 of 2
160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov
State of Utah
Department of Commerce
Division of Real Estate
REAL ESTATE RECIPROCITY APPLICATION
*RECIPROCITY EXISTS WITH GEORGIA,
MISSISSIPPI, AND ALBERTA*
Complete, sign, have notarized, and submit this form along with license histories, 2 completed Blue FD-258
fingerprint cards, fingerprint waiver, social security verification form and for agents a $157 non-refundable fee or
for brok
ers a $163 non-refundable fee, by mail or in person.
Name: _____________________
____________________________________ DOB:_____________________________________
Email: ________
_______________________ Phone: _______________________________ Cell: __________________________
Physical Address: _____________________________________________________________________________________________
Mailing
Address: _____________________________________________________________________________________________
Utah Company: _______________________________
______________ License Number: ________________________________
Utah Broker Signature: _____________________________________
__ License Number: ________________________________
APPLICATION FOR: (
) Sales Agent ( ) Associate Broker ( ) Branch Broker ( ) Principal Broker
**WARNING: Failure to accurately answer ALL questions may result in the loss or restriction of your license.**
YES
NO
1. Are you at least 18 years of age?
2. Do you attest that you have a high school diploma or GED?
3. Have you EVER had a professional or occupational credential (license, registration, certification, or
similar authorization to work in a professional or occupational capacity) denied, revoked, or suspended?
4. Have you EVER had a professional or occupational credential (license, registration, certification, or
similar authorization to work in a professional or occupational capacity) sanctioned? Sanctions include, but are
not limited to, having a credential restricted, limited, placed on probation, being required to pay a fine or
penalty, take education, or comply with any other condition?
5. Have you EVER been sanctioned or banned from engaging in any activity by Freddie Mac, Fannie
Mae, FHA (HUD), VA, or similar organization for any period of time or for any reason?
6. Have you EVER been ordered to cease and desist from any conduct related to a professional or
occupational credential (license, registration, certification, or similar authorization to work in a professional or
occupational capacity)?
7. Have you EVER allowed a professional or occupational credential (license, registration, certification,
or similar authorization to work in a professional or occupational capacity) to expire or lapse while you were
under investigation by a regulatory or licensing body, or while a regulatory action was pending against you?
8. Do you have knowledge of any complaint, investigation, or disciplinary action CURRENTLY
ongoing or pending against you by a regulatory or licensing body?
9. Have you EVER been convicted of, or pled guilty or nolo contendere to a felony, class A misdemeanor, class B
misdemeanor, or comparable criminal offense? A traffic offense can be prosecuted as a felony, class A
misdemeanor, class B misdemeanor, or comparable criminal offense. Where this is the case disclosure is
required.
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Rev. 0
6/03/2020
Page 2 of 2
160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov
State of Utah
Department of Commerce
Division of Real Estate
REAL ESTATE RECIPROCITY APPLICATION
Yes No
10. Have you EVER resolved a felony, class A misdemeanor, class B misdemeanor, or comparab
le
crim
inal offense through a plea in abeyance, diversion agreement, withheld judgment, or other method
whereby a charge was held in suspense during a period of time in which you were on probation or were
obligated to comply with conditions outlined by a court? A traffic offense can be prosecuted as a felony, class
A misdemeanor, class B misdemeanor, or comparable criminal offense. Where this is the case disclosure is
required.
11. Currently, are you aware of any investigation(s), indictment(s), or criminal charge(s) for any crime
in any jurisdiction which are pending against you?
12. Have you EVER been courts martial or discharged other than honorably from any branch of th
e
armed services?
13. Have you
EVER been required to register as a sex offender?
14.
Have you EVER had a judgment entered against you in a civil court or in a bankruptcy court on the
basis of fraud, misrepresentation, or deceit, or in any matter related to the purchase, sale, management,
finance, loan origination, or valuation of real estate?
15. Have you EVER been found in contempt of court?
I hereby certify that the answers I provided to the questions above are true and correct. If I am a non-resident of the State of Utah, I do
hereby appoint the Director of the Division of Real Estate as my agent in Utah upon whom process or pleadings may be served for and
on behalf of Real Estate Broker or Agent within the meaning of Utah Code Annotated 61-2.
YES answers require a detailed letter of explanation and copies of all court documents including charging and judgment
documents; court dockets; and proof of completion of probation and restitution orders and payment of fines and judgments.
Applicant Signature _____________________________________________________ Date _______________________________
State of _________________________ County of _________________________ Appeared before me this __________ day of
______________________, ___________, _______________________________________________, who deposes and says that the
information listed above is true to the best of his/her knowledge. (Notary)________________________________________________
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Rev 06/03/2020 Fax to: 801-526-4387 or Email to: realestate@utah.gov
CERTIFICATION OF LEGAL PRESENCE
FOR UTAH REAL ESTATE, MORTGAGE, APPRAISER, AND TIMESHARE
APPLICANTS
APPLICANTS PLEASE NOTE:
This document must be completed, signed, and submitted with your application to the Utah
Department of Commerce in order to obtain your license. For each section, check the statement
that applies to you and enter the data on the line provided before sending it to the Utah
Department of Commerce.
Industry/Type: Appraiser Appraiser Trainee Mortgage Real Estate
Timeshare License or NMLS number: _____________________
Social Security Number: _______________________________________________________
I certify under penalty of perjury that:
□ I am a citizen of the United States and I have a valid US Drivers License or US State ID.
License/State ID Number: ___________________ State: _____________________
□ I am a citizen of the United States and do not have a valid US Drivers License or US State
ID. Please attach a legible copy of your valid passport or other documentation to verify
you are a legal citizen of the United States.
□ I am a non-citizen of the United States, who is lawfully present in the United States and I
have a valid US Drivers License or US State ID.
License/State ID Number: ___________________ State: _____________________
□ I am a non-citizen of the United States, who is lawfully present in the United States and I
do not have a valid US Driver License or US State ID. Please attach a legible copy of your
current and valid government issued document showing evidence of authorization to work
in the United States.
I hereby certify that I have read and understood this document, and that the information I have
provided is true and accurate.
Name: __________________________________________
Signature: _______________________________________
Date: ___________________________________________
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160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov
State of Utah
Department of Commerce
Division of Real Estate
FINGERPRINT WAIVER
In connection with my application for a license with the Utah Division of Real Estate, I hereby authorize the
Division to obtain my fingerprints and to review my past and present employment and education records and to
conduct a criminal history background check in order to ascertain any and all information which may be
pertinent to my licensure qualifications. I do hereby release all government agencies including, but not limited
to, the Utah State Bureau of Criminal Identification, the Federal Bureau of Investigation, the Utah Division of
Real Estate, and the Utah Real Estate Commission, and their employees from any damages resulting from
furnishing such information.
WARNING: If information received from the Utah Bureau of Criminal Identification or the Federal Bureau of
Investigation indicates that I have failed to accurately disclose my criminal history to the Utah Division of Real
Estate, I understand that any real estate license issued to me will be immediately and automatically revoked.
REVIEW OF MY FBI RECORD: I understand that I have the right to obtain my criminal history by contacting
the FBI Field Office that serves my area for instruction on the procedure and any application fees. All Residents
of Utah should direct their inquiries to the Salt Lake Filed Office, 257 E 200 S, STE 1200, Salt Lake City, UT
84111. Telephone: (801) 579-1400
______________________________________
Prospective Licensee's Name-PLEASE PRINT
______________________________________ ___________________
Prospective Licensee's Signature Date
Rev.06/03/2020
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REAL ESTATE RECIPROCITY APPLICATION *RECIPROCITY EXISTS WITH GEORGIA, (Utah DRE)

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Completed 14 February 2021

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