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Fillable Printable Form 18479

Fillable Printable Form 18479

Form 18479

Form 18479

INDIANA AUCTIONEER COMMISSION
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204-2724
Telephone: (317) 234-3009
www.pla.IN.gov
DO NOT WRITE ABOVE THIS LINE
Type of action requested (please check one only): Examination only Reciprocal applicant
Page 1 of 2
Date fee paid (month, day, year)Application fee
Date issuance (month, day, year)License number issued
Receipt number
INSTRUCTIONS: 1. The fee for this application is $70.00, payable to the Indiana Professional Licensing Agency, in accordance with 812 IAC 1-1-35.
2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
FOR OFFICE USE ONLY
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
** This information is being requested for workforce statistical purposes only; disclosure is voluntary.
APPLICATION FOR EXAMINATION FOR AUCTIONEER LICENSE
OR LICENSE BY RECIPROCITY
State Form 18479 (R17 / 9-17)
Approved by State Board of Accounts, 2017
APPLICANT INFORMATION
Date of graduation (month, day, year)
Web address
If currently licensed as a real estate broker in Indiana, give license number:
Broker license number
Has your application for a license as an auctioneer or apprentice auctioneer ever been rejected in this or any other state?
If so, explain on a separate sheet where, exact date, and full details of rejection.
License number
Has your license as an auctioneer or apprentice auctioneer ever been disciplined in this or any other state?
If so, explain on a separate sheet where, exact date and full details of discipline.
If so, where?
Have you ever been licensed in this or any other state as an auctioneer or apprentice auctioneer?
Issuance date of license (month, day, year)
Name of Pre-Licensing school
Business telephone number
( )
Business address (number and street, city, state, and ZIP code)
Name of business
Name of applicant (last, first, middle)
Date of birth (month, day, year)
Address of applicant (number and street or rural route)
Social Security number
*
Telephone number (daytime)
( )
City, state, and ZIP code
E-mail address
Place of birth (city and state or country)
Gender **
Male Female
Race **Ethnicity **
Are you the spouse of a member of the military who is assigned to a duty station in Indiana?
(Optional)
Yes No
Are you an active duty member of the military? (Optional)
Yes No
Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)
I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).
Yes No
Yes No
Yes No
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Have you committed an act which would constitute a ground for disciplinary sanction under IC 25-1-11-5?
If so, please explain in an attached sworn affidavit.
Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor,
or felony in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
Have you read and do you understand the provisions of The Auctioneer and Auction Licensing Act in accordance with
IC 25-6.1-1-1?
Will you display your license in a conspicuous manner in your place of business?
Do you understand that an auctioneer license must be kept in your custody and immediately returned by you to the
INDIANA AUCTIONEER COMMISSION upon suspension or revocation?
Signature of applicant
Date (month, day, year)
Signature of applicant
APPOINTMENT OF INDIANA AUCTIONEER COMMISSION AS AGENT OF AUCTIONEER TO
ACCEPT SERVICE OF PROCESS OR PLEADING:
I, ___________________________________ of the city of _______________________________ , State of _____________ , do hereby appoint the
Indiana Auctioneer Commission as my agent, for the receipt of service of process or pleading in said State of Indiana, upon which Indiana Auctioneer
Commission process or pleadings against me may be served. I do hereby consent that suits and actions may be commenced against me in the proper
court of any county in the State of Indiana in which the plaintiff may reside by the service of any process or pleadings authorized by the laws of the State
of Indiana on the Indiana Auctioneer Commission, and I do hereby stipulate and agree that such service of process or pleadings on the Indiana Auctioneer
Commission shall be taken and held in all courts to be as valid and binding upon me as if due service had been made upon me personally within the State
of Indiana.
The foregoing appointment, consent, stipulation, and agreement shall be deemed to be as is irrevocable.
Complete section I of this application and pay required fees.
Please include a copy of your certificate or course completion
with this application.
If you have not completed your education, you must provide a copy of your
certificate of course completion at the examination site at the time of admittance.
Please check here if so:
EXAMINATION ONLY
APPLICATION AFFIRMATION
I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete, and correct.
Date (month, day, year)
If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation
of the license or permit issued pursuant to this application.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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