Dealer Application {COM 3622}

Page 1 of 2 COM 3622 (REV. 09/2012) An Equal Opportunity Employer and Service Please visit our website at www.com.ohio.gov/real 614 | 466-4100 Fax 614 | 644-0584 TTY/TDD: 800 | 750-0750 FOR DIVISION USE ONLY LICENSE FEE ($150.00) FILE NUMBER LICENSE NUMBER EXAMINATION FEE ($75.00) LICENSE APPROVED/REFUSED/WITHDRAWN DATE OF ISSUANCE INSTRUCTIONS: FORM 27 DEALER APPLICATION FOREIGN REAL ESTATE (Pursuant to Chapter 4735.27 of the Ohio Revised Code) This application is for an individual, partnership, unincorporated association, or any similar from of business organization requesting an Ohio foreign real estate deale license. Incomplete application forms will delay the application process. Application forms must be typed in black ink only. The license fee is $150.00 and is nonrefundable. The examination fee is $75.00 and is nonrefundable after the Division has scheduled the applicant for the examination. A check or money order payable to the Division of Real Estate must accompany this application. Do not send cash. FORM 27SOP: CONSENT TO SERVICE OF PROCESS must accompany this application. 1. NAME OF APPLICANT (LAST, FIRST, MI) 2. DATE OF BIRTH (mm/dd/yyyy) 3. FORM OF BUSINESS ORGANIZATION PARTNERSHIP UNICORPORATED ASSOCIATION SOLE PROPRIETORSHIP OTHER (Specify) 4. SOCIAL SECURITY NUMBER / FEDERAL TAX ID NUMBER 5. RESIDENTIAL ADDRESS (STREET, CITY, COUNTY, STATE, ZIP CODE) PHONE 6. EDUCATION 7. PRINCIPAL OFFICE ADDRESS (STREET, CITY, COUNTY, STATE, ZIP CODE) BUSINESS PHONE 8. DATE AND PLACE OF ORGANIZATION OF THE BUSINESS: 9. GENERALLY DESCRIBE THE CURRENT NATURE OF THE BUSINESS OF THE APPLICANT 10. HAS THE APPLICANT EVER BEEN LICENSED AS A REAL ESTATE BROKER IN OHIO OR ANY OTHER STATE? NO YES Provide a copy of the certificate(s) of licensure 11. HAS THE APPLICANT EVER BEEN LICENSED AS A FOREIGN REAL ESTATE DEALER IN OHIO OR ANY OTHER STATE? NO YES Provide the licensing body, date and type of license American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 ATTACH ANY APPLICABLE INFORMATION IN RESPONSE TO THE QUESTIONS BELOW. 12. PROVIDE A LIST OF BUSINESS ADDRESSES OF THE APPLICANT FOR THE PRECEDING TEN YEARS. 13. PROVIDE A LIST OF ALL BRANCH OFFICES LOCATED IN OHIO AND ELSEWHERE. (NAME, STREET, CITY, STATE, ZIP CODE) 14. IF APPLICABLE, PROVIDE A CURRENT LIST OF THE NAMES AND ADDRESSES (BUSINESS AND RESIDENTIAL) OF ALL OF THE APPLPARTNERS, OFFICERS, DIRECTORS, TRUSTEES OR MANAGERS ACCOUNTING FOR ANY LIMITATION OF LIABILITY. 15. PROVIDE A LIST OF THE NAMES AND ADDRESSES OF ALL SALESPERSONS TO BE EMPLOYED DURING THE CALENDAR YEAR IN CONNECTION WITH THE SALE OF FOREIGN REAL ESTATE IN OHIO. (NOTE: A SEPARATE FORM 28 APPLICATION MUST BE FILED FOR EACH SALESPERSON.) If the answer to any of the following is y attach a schedule identifying each such case and the parties involved, briefly describing the circumstances, stating the court or agency involved and the reference file number used by such court or agency, and providing such further information which may be useful to the Division in understanding the case. 16. State whether the applicant, or any person named in question 14, or any other person directly or indirectly controlling or controlled by the applicant, including any employee: a. Has been found by any state regulatory agency or the U.S. Department of Housing and Urban Development to have made or caused to have been made in any application, filing or report required to be filed with the Department or in any proceeding before such agencies with respect to such filing, any statement which was at the time and in light of the circumstances under which it was made false or misleading with respect to any material fact which was required to be stated therein. NO YES b. Has been convicted within the past ten years of any felony or misdemeanor: (1) involving the purchase or sale of any interest in real estate situated within or outside of Ohio; (2) arising out of the conduct of the business of a broker or dealer; (3) involving embezzlement, fraudulent conversion, or misappropriation of funds or securities; (4) involving moral turpitude or municipal civil rights pertaining to discrimination in housing; or (5) involving violation of section 1341, 1342, or 1343 of Title 18, United States Code which includes mail fraud and fraud by wire (including telephone, telegraph, radio or television.) NO YES c. Has been convicted within the past ten years of a felony or any violation of penal law in another jurisdiction, state or federal. NO YES d. Has been the subject of any civil or criminal proceedings or other disciplinary action in any state for a violation of a securities law, real estate law or regulation. NO YES e. Is or has been permanently or temporarily enjoined by order, judgment or decree of any court or administrative agency from acting as a broker or dealer in connection with the purchase or sale of foreign real estate. NO YES f. Has been denied registration or licensure with a state or federal agency, or had a license or registration with a state or federal agency suspended or revoked. NO YES THE APPLICANT MUST COMPLETE THE FOLLOWING CERTIFICATION The undersigned applicant hereby states that the information given in this application is accurate and complete and that such information is furnished for the purpose of procuring an individual corporate foreign real estate dealer license pursuant to Section 4735.27 of the Ohio Revised Code. SIGNATURE OF APPLICANT DATE American LegalNet, Inc. www.FormsWorkFlow.com