New York Real Estate Salesperson Application

Real Estate Salesperson Application

NYS Department of State
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001

Read the Instruction Sheet for details before completing this application form. You must answer each question and TYPE or PRINT responses in ink.

Applicant’s Last Name: First Name: M.I.: Suffix:

Home Address: Apt/Unit:

City: State: ZIP+4: County:

Daytime Telephone Number: Social Security Number:

E-mail Address: Has this e-mail address changed since taking examination? Yes No

Business Name: Office License/Unique ID Number:

Business Address: Location is Principal Office
  Location is Branch Office

City: State: ZIP+4: County:

1 Background Data

1. What is your date of birth?

2. Have you ever applied for or been issued a real estate broker’s or salesperson’s license in this state?
Yes No
If “Yes,” in what year? Under what name?
License/Unique ID Number:

3. Have you ever been convicted in this state or elsewhere of any criminal offense that is a misdemeanor or a felony?
Yes No

4. Are there any criminal charges pending against you in any court in this state or elsewhere?
Yes No

5. Has any license or permit issued to you or a company in which you are or were a principal in New York State or elsewhere ever been revoked, suspended or denied?
Yes No

2 Certification of Satisfactory Completion

Name of School:

Real Estate Salesperson Course (Code) # S-

This certifies that has satisfactorily completed a 75-hour salesperson qualifying course in real estate approved by the Secretary of State in accordance with the provisions of Chapter 868 of the Laws of 1977; that attendance of the student was in compliance with the law and that a passing grade was achieved on the final examination.

The course was completed on

3 Child Support Statement — You must complete this section. If you do not complete it, your application will be returned.

“X” A or B, below

I, the undersigned, do hereby certify that (You must “X” A or B, below):

A. I am not under obligation to pay child support. (SKIP “B” and go directly to Applicant Affirmation).

B. I am under obligation to pay child support (You must “X” any of the four statements below that are true and apply to you):

I do not owe four or more months of child support payments.

I am making child support payments by income execution or court approved payment plan or by a plan agreed to by the parties.

My child support obligation is the subject of a pending court proceeding.

I receive public assistance or supplemental social security income.

4 Applicant Affirmation — I affirm, under the penalties of perjury, that the statements made in this application are true and correct. I further affirm that I have read and understand the provisions of Article 12-A of the Real Property Law and the rules and regulations promulgated thereunder.

Applicant Print Name:

5 DMV Consent Section — IMPORTANT Information Regarding Your Photo ID

The Department of State produces photo ID cards in cooperation with the NYS Department of Motor Vehicles (DMV). If you have a current NYS Driver License or Non-Driver ID card, please provide your 9-digit DMV ID Number in the space provided below. Then read the informed consent and sign this form. If you do not have a current NYS photo Driver License or Non-Driver ID card, please have your photo taken at any nearby DMV office BEFORE you complete this application. For more details, refer to our enclosed notice, "Request for Photo ID."

INFORMED CONSENT

I authorize the NYS Department of State and the NYS Department of Motor Vehicles (DMV) to produce an ID card bearing my DMV photo. I understand that DMV will send this card to the address I maintain with the Department of State. I also understand that the Department of State and DMV will use my DMV photo to produce all my subsequent ID Cards for as long as I maintain my license/registration with the Department of State.

DMV ID #:

6 Association Statement — I am sponsoring this application in accordance with the Real Property Law, §441.1(d).

Broker License/Unique ID Number:

Broker Print Name:

Please remember to include with this application any required explanations and statements along with your application fee (checks should be made payable to NYS Department of State).

It is important that you and/or your broker update any changes to your business address through your online account so you can continue to receive renewal notices and any other notifications pertinent to your license.