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Transfer Reactivation Application COM 3576 - Ohio
| Transfer Reactivation Application Form. This is a Ohio form and can be used in Broker Real Estate Department Of Commerce Statewide . |
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Ohio Department of Commerce Division of Real Estate & Professional Licensing 77 South High Street · 20th Floor Columbus, OH 43215-6133 (614) 466-4100 FAX (614) 644-0584 www.com.ohio.gov Ted Strickland Governor Kimberly A. Zurz Director BROKER TRANSFER / REACTIVATION APPLICATION This form is interactive. You may, before printing, type your responses directly onto the form. Otherwise, this form must be typewritten or printed neatly in black ink. Incomplete applications and applications that are filled out incorrectly will be returned for correction. A check or money order for any fees, made payable to: Division of Real Estate & Professional Licensing must be remitted with this application. Cash will not be accepted. The original broker license must be returned before a new license will be issued. Be certain to complete the applicable certifications on Page 2. APPLICANT INFORMATION FILE NUMBER HOME ADDRESS CITY Check if new. STATE ZIP CODE + 4 LAST NAME FIRST NAME FEE $25.00 FOR DIVISION USE ONLY FEE AMOUNT FILE NUMBER CE DUE DATE BROKER NUMBER ISSUE DATE MIDDLE INITIAL OR NAME SUFFIX DATE OF BIRTH (mm/dd/yyyy) HOME PHONE ( PROSPECTIVE BROKER INFORMATION FILE NUMBER BUSINESS ADDRESS CITY OFFICIAL CORPORATION, L.L.C., PARTNERSHIP, OR ASSOC. NAME DOING BUSINESS AS (D.B.A.) NAME STATE ZIP CODE + 4 ) BUSINESS PHONE ( ) REASON FOR COMPLETING THIS FORM (Check all that apply. Remit only one $25 application fee per form even if you check multiple boxes.) TRANSFER TO A NEW BROKERAGE (include $25 application fee, include the original brokerage license and addendum) TRANSFER FROM A CORPORATE BROKERAGE TO AN INDIVIDUAL (SOLE) BROKER (attach a letter from the bank where you have established your trust or special account, include your account name and number, include $25 application fee) REACTIVATE LICENSE FROM INACTIVE (ON DEPOSIT) OR RETIRED STATUS (if reactivating from retired status, also include proof of completion of all outstanding continuing education, include $25 application fee, include the brokerage license and addendum) REACTIVATE LICENSE TO ACTIVE STATUS FROM RENEWAL SUSPENSION (include fee see chart on Page 2, include the brokerage license and addendum) REACTIVATE LICENSE TO INACTIVE OR RETIRED STATUS FROM RENEWAL SUSPENSION (skip Broker Information, include fee see chart on Page 2) REACTIVATE LICENSE TO ACTIVE STATUS FROM POST LICENSE EDUCATION SUSPENSION (include the brokerage license and addendum, include $25 application fee) REACTIVATE LICENSE TO INACTIVE STATUS FROM POST LICENSE EDUCATION SUSPENSION (skip Broker Information, include $25 application fee) REACTIVATE LICENSE TO ACTIVE STATUS FROM AN ENFORCEMENT ACTION (include $25 application fee, include the brokerage license and addendum) REACTIVATE LICENSE TO INACTIVE STATUS FROM AN ENFORCEMENT ACTION (include $25 application fee) PLACE BROKER LICENSE IN INACTIVE (ON DEPOSIT) STATUS AND REQUEST SALESPERSON LICENSE (include $25 application fee, include the brokerage license and addendum) PLACE BROKER LICENSE IN INACTIVE (ON DEPOSIT) STATUS (no fee, include the brokerage license and addendum. If your license is lost, please use the Change Application Individual [COM 3628]) PLACE LICENSE IN RETIRED STATUS (You may place your license in retired status if you are 70 years of age or older. You are still required to complete your renewal every three years; however you are exempt from the continuing education requirements.) NOTICE: Evidence that payment has been refused by the drawer's bank upon a check drawn to the order of the Ohio Division of Real Estate & Professional Licensing shall constitute prima facie evidence of misconduct and shall constitute a violation of division (A)(6) of section 4735.18 of the Revised Code. "An Equal Opportunity Employer and Service Provider" COM 3576 (Rev. 01/2008) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Individuals reactivating from Renewal Suspension owe fees according to the following schedule. The year 2006 was a transition year to move onto a Three-Year-Renewal schedule. This schedule will coincide with the Continuing Education Cycle of the license. Renewal Due 2006 2006 2006 2007 C.E. Due 2006/09 2007 2008 2007/10 Renewal Fee $147.00 $49.00 $98.00 $147.00 Late Renewal Penalty $73.50 $24.50 $49.00 $73.50 Reactivation $25.00 $25.00 $25.00 $25.00 Total $245.50 $98.50 $172.00 $245.50 ETHICAL CONDUCT AND LEGAL HISTORY PLEASE ATTACH A COMPLETE EXPLANATION FOR ANY QUESTIONS ANSWERED "YES". QUESTIONS CONCERNING PROFESSIONAL LICENSES APPLY TO ALL PROFESSIONAL LICENSES REGARDLESS OF PROFESSION. SINCE your most recent filing of any of the following documents: original application for real estate licensure in Ohio, annual renewal or transfer/reactivation application; have you: YES YES YES YES YES YES NO NO NO NO NO NO been disciplined in any manner by any public entity or professional or trade association for any violation of any professional licensing law, regulation or ethical rule? been refused or denied any professional license or registration by any public entity? had any professional license revoked, suspended or limited in any way for any reason? been notified by any public entity or professional or trade association that you were under investigation for any violation of any professional licensing law, regulation or ethical rule? been the subject of any unsatisfied judgments? been convicted of, plead guilty to or been granted intervention in lieu of conviction for any unlawful conduct excluding minor traffic violations? THE APPLICANT MUST COMPLETE THE FOLLOWING CERTIFICATION I certify that all of the statements on this application and all of the attached materials are complete and accurate. I understand that any false statement on this form or any of the attached materials may subject me to criminal prosecution and the loss of my Ohio real estate license. ___________________________________ _______________ SIGNATURE OF APPLICANT DATE THE SPONSORING BROKER MUST COMPLETE THE FOLLOWING CERTIFICATION ONLY IF THE APPLICANT IS REQUESTING A SALESPERSON LICENSE (PLACING BROKER ON DEPOSIT) I hereby certify that, from the investigations made by me, I find the above listed applicant for a real estate license is honest, truthful and of good reputation. I understand that any false statement on this form that is known to me at the time of my signing may subject me to criminal prosecution and the loss of my Ohio real estate license. ___________________________________ _______________ NAME
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