ESRein Rev 5/21
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
License Services Division
450 Columbus Blvd, Ste. 801
Hartford, CT 06103
Email: dcp.licenseservices@ct.gov
Website: www.ct.gov/dcp
Real Estate Salesperson Reinstatement Form
This form is required for any salesperson whose license has expired not more than two (2) years past the expiration
date and must be submitted with the applicable fee indicated on the instructions.
Salesperson Information:
First Name Middle Initial Last Name
Street Address
City State Zip Code
Telephone Number
Social Security Number Email address to be used to receive all correspondence from this office
Real Estate Salesperson License Number Expiration Date of License
1. Have you been convicted of a felony crime since the date of your last renewal? YES NO If yes, attach a statement of
explanation.
2. Have you ever been convicted of a crime related to forgery, embezzlement, obtaining money under false pretenses, extortion,
criminal conspiracy to defraud, or any like offenses?
YES NO If yes, attach a statement of explanation.
3. Have you ever had a real estate license refused, suspended or revoked in any State? YES NO If yes, attach a statement
of explanation.
4. Have you completed the required continuing education? YES NO You must attach copies of the applicable
documentation confirming your compliance with the required CE.
Sponsoring Broker Information:
Legal Name of Sponsoring Broker Sponsoring Broker License Number
Street Address
City State Zip Code
Signature of Sponsoring Broker Date
Certification:
For Official Use Only
I certify, under penalty of law (Section 53a-157b, a Class A Misdemeanor) that the information provided in this application is the
truth to the best of my knowledge.
_____________________________________________________________________________ ______________________________
Signature of Applicant Date
