Fillable Printable Impediment License Renewal Form 20140409
Fillable Printable Impediment License Renewal Form 20140409
Impediment License Renewal Form 20140409
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REV. 4/09/2014 160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov • Email: [email protected]
State of Utah
Department of Comme rc e
Division of Real Estate
IMPEDIMENT LICENSE RENEWAL FORM
Complete, sign, and submit this form along with the non-refundable renewal fee to
the Utah Division of Real Estate by fax, mail, email, or in person at the address at the bottom of the page.
Name: ____________________________________________________________________________________________
License #: ______________________________________________ Expiration: _______________________________
Phone: _________________________________________________ Email: ___________________________________
Physical Address: ___________________________________________________________________________________
Public/Mailing Address: ______________________________________________________________________________
APPLICATION FOR: ( ) Appraiser ( ) Real Estate Agent ( ) Real Estate Broker*
WARNING: Failure to accurately answer ALL questions may result in the loss or restriction of your license. If
you are unsure about how to answer any of these questions, consult competent legal counsel.
YES NO
1. Since your last renewal, have you had a professional or occupational credential (license,
registration, certification, or similar authorization to work in a professional or occupational
capacity) denied, revoked, or suspended?
2. Since your last renewal, have you had a professional or occupational credential (license,
registration, certification, or similar authorization to work in a professional or occupational capacity)
sanctioned? Sanctions include, but are not limited to, having a credential restricted, limited, placed on
probation, being required to pay a fine or penalty, take education, or comply with any other condition?
3. Since your last renewal, have you been sanctioned or banned from engaging in any activity by
Freddie Mac, Fannie Mae, FHA (HUD), VA, or similar organization for any period of time or for any
reason?
4. Since your last renewal, have you been ordered to cease and desist from any conduct related to a
professional or occupational credential (license, registration, certification, or similar authorization to work in
a professional or occupational capacity)?
5. Since your last renewal, have you allowed a professional or occupational credential (license,
registration, certification, or similar authorization to work in a professional or occupational capacity) to
expire or lapse while you were under investigation by a regulatory or licensing body, or while a regulatory
action was pending against you?
( ) Check ( ) Visa ( ) MasterCard ( ) American Express
Make checks payable to: Utah Division of Real Estate
Card # __________________________________Expires_______ CVC#______
Signature ________________________________________________________
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REV. 4/09/2014 160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov • Email: [email protected]
State of Utah
Department of Comme rc e
Division of Real Estate
IMPEDIMENT LICENSE RENEWAL FORM
YES NO
6. Do you have knowledge of any complaint, investigation, or disciplinary action CURRENTLY
ongoing or pending against you by a regulatory or licensing body?
7. Since your last renewal, have you been convicted of, or pled guilty or nolo contendere to a felony,
class A misdemeanor, class B misdemeanor, or comparable cri minal offense? A traffic offense can be
prosecuted as a felony, class A misdemeanor, class B misdemeanor, or comparable criminal offense. Where
this is the case disclosure is required.
8. Since your last renewal have you resolved a felony, class A misdemeanor, class B misdemeanor, or
comparable criminal offense through a plea in abeyance, diversion agreement, withheld judgment, or other
method whereby a charge was held in suspense during a period of time in which you were on probation or
were obligated to comply with conditions outlined by a court? A traffic offense can be prosecuted as a
felony, class A misdemeanor, class B misdemeanor, or comparable criminal offense. Where this is the case
disclosure is required.
9. Currently, are you aware of any investigation(s), indictment(s), or criminal charge(s) for any crime
in any jurisdiction which are pending against you?
10. Since your last renewal, have you been courts martial or discharged other than honorably from
any branch of the armed services?
11. Since your last renewal, have you been required to register as a sex offender?
12. Since your last renewal, have you had a judgment entered against you in a civil court or in a
bankruptcy court on the basis of fraud, misrepresentation, or deceit, or in any matter related to the
purchase, sale, management, finance, loan origination, or valuation of real estate?
13. Since your last renewal, have you been found in contempt of court?
I hereby certify that I have read each disclosure question stated above, that I understand each question, and that I have
answered the questions truthfully and accurately. I agree to be bound by the answers I have provided, and I understand that
I may be sanctioned if any of my answers are found to be misleading or incorrect.
YES answers require a detailed letter of explanation and copies of all court documents including charging and
judgment documents; court dockets; and proof of completion of probation and restitution orders and payment of
fines and judgments.
*For Principal Brokers: by signing this form I certify that all real estate trust accounts are current and in compliance with
administrative rules AND that the business with which my license is affiliated is current and in good standing with the
Division of Corporati
ons.
Signature ___________________________________________________ Date ____________________
Rev 3/3/2014 Fax to: 801-526-4387 or Email to: [email protected]
CERTIFICATION OF LEGAL PRESENCE
FOR UTAH REAL ESTATE, MORTGAGE, APPRAISER, AND TIMESHARE
APPLICANTS
APPLICANTS PLEASE NOTE:
This document must be completed, signed, and submitted with your application to the Utah
Department of Commerce in order to obtain your license. For each section, check the statement
that applies to you and enter the data on the line provided before sending it to the Utah
Department of Commerce.
Industry/Type: Appraiser Appraiser Trainee Mortgage Real Estate
Timeshare License or NMLS number: _____________________
Social Security Number: _______________________________________________________
I certify under penalty of perjury that:
□ I am a citizen of the United States and I have a valid US Drivers License or US State ID.
License/State ID Number: ___________________ State: _____________________
□ I am a citizen of the United States and do not have a valid US Drivers License or US State
ID. Please attach a legible copy of your valid passport or other documentation to verify
you are a legal citizen of the United States.
□ I am a non-citizen of the United States, who is lawfully present in the United States and I
have a valid US Drivers License or US State ID.
License/State ID Number: ___________________ State: _____________________
□ I am a non-citizen of the United States, who is lawfully present in the United States and I
do not have a valid US Driver License or US State ID. Please attach a legible copy of your
current and valid government issued document showing evidence of authorization to work
in the United States.
I hereby certify that I have read and understood this document, and that the information I have
provided is true and accurate.
Name: __________________________________________
Signature: _______________________________________
Date: ___________________________________________
