Fillable Printable Form 55611
Fillable Printable Form 55611
Form 55611
STATUS INFORMATION
* Your Social Security number is requested by this agency in accordance with Indiana Code 4-1-8-1. Disclosure is mandatory, and this record cannot be processed
without it. Social Security numbers are available to the Indiana Department of Revenue.
APPLICATION FOR DESIGNATION AS A MANAGING BROKER
State Form 55611 (R2 / 8-16)
LICENSE NUMBER
DATE DESIGNATION APPROVED (month, day, year)
INDIANA REAL ESTATE COMMISSION
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-3009
E-mail: [email protected]
www.pla.IN.gov
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden or previous)
Date of birth (month, day, year)
Address (number and street or rural route)
City
Work telephone number (include area code)
State
Social Security number *
ZIP code
( )
APPLICANTS MUST ATTACH AN ORIGINAL COPY OF THEIR CERTIFICATE OF COURSE COMPLETION.
Date of course completion (month, day, year)
Name of Course Provider
Location (city and state)
MANAGING BROKER COURSE INFORMATION
After my designation is approved, I will:
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Remain with my current broker as an associate.
Hold my own license as a sole proprietor.
Hold my own license as the broker primarily responsible to the commission of a licensed broker company.
(Please complete broker company section below.)
Place of birth (city and state)
E-mail address (required)
Residential telephone number (include area code)
( )
BROKER COMPANY INFORMATION
Name of Real Estate Broker Company
Address (number and street or rural route)
City
Signature of broker accepting responsibility
State
License number of Company
ZIP code
Registration number of Indiana Course Provider
Date signed (month, day, year)
Business telephone number (include area code)
( )
Number of course hours completed
INSTRUCTIONS: 1. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
Are you the spouse of a member of the military who is assigned to a duty station in Indiana (Optional)?
Yes No
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AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize, request and direct any person, firm, officer, corporation, association, organization, or institution to release to the Indiana Professional
Licensing Agency and the Indiana Real Estate Commission, any files, documents, records, or other information pertaining to the undersigned requested
by the Agency, or the Commission, or any of their authorized representatives, in connection with the processing of my application for licensure.
I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to
such inspection or furnishing of any such information.
I further authorize the Indiana Professional Licensing Agency and the Indiana Real Estate Commission, to disclose to the aforementioned persons, firms,
officers, corporations, associations, organizations and institutions any information, which is material to my application, and I hereby specifically release
the Agency, and the Commission from any and all liability in connection with such disclosures.
A photostatic copy of this authorization has the same force and effect as the original.
AFFIRMATION
I hereby swear and affirm that I have read the above statements and agree to the same.
Signature of applicant Date signed (month, day, year)
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I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Date signed (month, day, year)
Signature of applicant
APPLICATION AFFIRMATION
4. Has disciplinary action ever been taken regarding any professional license, certificate, registration or permit that you currently
hold or have previously held?
2. Have you ever been denied license, certification, registration, or permit to practice real estate or any other profession in this or
any other state?
3. Has any complaint been filed against you in the State of Indiana, or in any other state, regarding any professional license you
currently hold or have previously held or have you practiced real estate or appraising as defined by IC 24-34.1 without a license?
1. 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?
Yes No
Yes No
Yes No
Yes No
QUESTIONS
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
