SP-1 OF 3 - Government of New Jersey



CHECK ALL APPROPRIATE BOXESSALESPERSON ORBROKER-SALESPERSONAPPLICATION FOR:REINSTATEMENT OF UNRENEWED LICENSECHANGE OF NAMETRANSFER WITHIN CURRENT LICENSE TERMAPPLICATION FEECHANGE OF STATUSCHECK ALL APPROPRIATE BOXES SALESPERSONBROKER - SALESPERSON FORMCHECKBOX REINSTATEMENT OF UNRENEWED LICENSE(See Instruction #5 below)$150.00 FORMCHECKBOX REINSTATEMENT OF UNRENEWED LICENSE(See Instruction #5 below)$250.00 FORMCHECKBOX CHANGE OF NAME$50.00 FORMCHECKBOX CHANGE OF NAME$50.00 FORMCHECKBOX TRANSFER WITHIN CURRENT LICENSE TERM$25.00 FORMCHECKBOX TRANSFER WITHIN CURRENT LICENSE TERM$25.00 FORMCHECKBOX APPLICATION FEE ONLY$50.00 FORMCHECKBOX APPLICATION FEE ONLY$50.00 FORMCHECKBOX CHANGE OF STATUS$50.00 FORMCHECKBOX CHANGE OF STATUS$50.00NO PERSONAL CHECKS ACCEPTEDNO PERSONAL CHECKS ACCEPTEDDATE://PROCESSOR:EFFECTIVEDATE://(mm)(dd)(yy)(mm)(dd)(yy)***** BLOCK DIRECTLY ABOVE FOR NEW JERSEY REAL ESTATE LICENSING SERVICES BUREAU USE ONLY *****- APPLICATION INSTRUCTIONS -1.All Applications must include only one (1) of the following payment types made payable to “The State Treasurer of New Jersey”.Acceptable Payment Types only: Broker Business Account Check, Bank Cashier or Certified Check or Money Order Unacceptable payment types: Personal Checks, Cash or Credit Cards, etc.2.Any dishonored payment types received in connection with an Application Fee received for a NJ Real Estate License is subject to a NJ Real Estate Commission (NJREC) Administrative Penalty of $500.00.3.If the submitted Application includes a Change of Name, attach a complete, and legible, legal copy of the Marriage Certificate, or Divorce Decree, or Court Order indicating the legal name change with the additional fee noted at the top.4.Disclosure of your legal Social Security Number is mandatory for all Child Support Enforcement purposes.The NJREC’s authority to compel disclosure of a Social Security Number is established at P.L. 1996, c.7 and N.J.A.C. 11:5-3.5.Unless otherwise directed, the NJREC will also use your Social Security Number for internal identification purposes.Place an “X” inside the square to the right, if you object to the NJREC doing so: FORMCHECKBOX 5.Applicants seeking to re-activate an un-renewed License must present one (1) of the following legal official document types to the Sponsoring Broker [Broker of Record (BOR)], specifically: If a USA citizen, attach a copy of Birth Certificate or a USA Passport establishing legal USA citizenship OR if a legally present non-USA citizen, attach a copy of INS form I-551 “Green Card”.- APPLICANTS - PLEASE TYPE, OR PRINT, THE FOLLOWING INFORMATION CLEARLY AND LEGIBLY ---Applicant NJREC Lic. Ref. # (7 numbers)Employing Broker FirmNJREC Lic. Ref. # (7 numbers)Legal Social Security Number Full Legal Name of Applicant: Last Name, First Name, MI Full Legal Home Address: Street Number and NameCountyCityStateZip Code + 4Telephone # with Area CodeComplete E-Mail AddressDate of Birth (mm/dd/yy)TO BE COMPLETED BY APPLICANT - ALL QUESTIONS MUST BE ANSWERED LEGIBLY AND IN ENTIRETYYESNO1.With the exception of motor vehicle violations, since your last New Jersey Real Estate License was last issued or renewed have you been convicted of a crime, misdemeanor, disorderly persons offense in the State of New Jersey, any other state or by the federal government, or are you presently on probation or parole? FORMCHECKBOX FORMCHECKBOX 2.Is there a criminal complaint, disorderly persons charge, a criminal accusation or criminal information presently pending against you or are you presently under indictment in New Jersey, or any other State or by the federal government, or are you presently enrolled in New Jersey’s Pre-Trial Intervention (PTI) program, or any similar State, or Federal, program involving the deferral of the disposition or sentencing in a criminal matter? FORMCHECKBOX FORMCHECKBOX 3.Have you ever had a real estate or other professional license, certification or similar credential revoked, suspended, surrendered in lieu of formal prosecution, or denied in New Jersey or any other state? FORMCHECKBOX FORMCHECKBOX 4.Do you have a child support obligation on which there is an arrearage due that equals or exceeds the amount of child support payable for six months, or are you the subject of a child support related warrant, or during the past six (6) months have you failed to provide any court-ordered health care coverage, or have you failed to respond to a subpoena relating to a paternity or child support proceeding? FORMCHECKBOX FORMCHECKBOX 5.Are you UNDER the age of 18 at the time of signing this application? FORMCHECKBOX FORMCHECKBOX 6.Are you currently licensed, or were you previously licensed, by the NJ Real Estate Commission? If “YES”, give date of last licensure and the name of previous Employing Broker/Company in the area directly below: FORMCHECKBOX FORMCHECKBOX Date (mm/dd/yy)Full Legal Name of Corporation, Employing Broker or Partnership7.Are you a high school graduate or the holder of a G.E.D. (Graduate Equivalent Diploma)? FORMCHECKBOX FORMCHECKBOX 8.Do you currently hold a real estate license issued by another state? If “YES”, list the one, or more, US State(s) below: FORMCHECKBOX FORMCHECKBOX 9.I have completed, in entirety, the correct Continuing Education (CE) credits required to re-instate my NJ Real Estate license FORMCHECKBOX FORMCHECKBOX If any of the answers to Questions 1 through 4 above are “YES”, give particulars below, including a copy of any indictment(s), judgement of conviction(s), or order(s), or revocation(s) and/or suspension(s). If particulars and copies, previously supplied, or if applicant was re-instated by order of NJREC, check this box FORMCHECKBOX THE APPLICANT:Under penalty, or perjury, I hereby certify that: the information I entered on all sides of this application is true and correct; the New Jersey Real Estate Commission may rely on its truthfulness in considering this application; I am a citizen of the U.S. or legally present in the U.S.; and a written employment agreement, as required by N.J.A.C. 11:5-4.1, has been completed and that I have a copy of that signed agreement in my possession.Making a false statement regarding a child support, paternity or court ordered health care coverage matter may subject you to contempt of court.PRINT Full Legal Name (First, MI, Last)SIGN Full Legal Name (First, MI, Last)DATE (mm/dd/yy)NJREC License Reference Number (7 numbers) of Corporation, Partnership or Employing BrokerFull Legal Name of Corporation, Partnership, or Employing BrokerFull Legal Registered Trade Name of Employing Broker, or Partnership or fictitious name of Corporation, if anyCountyFull Business Address (Street Number and Name) of Corporation, Partnership, or Employing BrokerBusiness Phone # w/Area CodeCityStateZip Code + 4THE EMPLOYING BROKER, OR BROKER OF RECORD, OR HOLDER OF POWER OF ATTORNEY FILED UNDER THE NJREC:I, under penalty, or perjury, hereby certify that: the applicant is authorized to apply for a license under my supervision, I am not aware of any information which reflects adversely upon his/her good moral character. (If broker is aware of such information, attach a separate letter providing details.)I further certify that: the information provided on this application is true and correct; the New Jersey Real Estate Commission may rely on its truthfulness in considering this application; a written employment agreement, as required by N.J.A.C. 11:5-4.1 has been completed and that I have a copy of the signed agreement in my possession; and that in the case of an application to reinstate an un-renewed license, the applicant has presented a birth certificate or U.S. passport establishing his/her U.S. Citizenship or an INS Form I-551 (Green Card) establishing their legal presence in the U.S.I am aware that this applicant is PROHIBITED BY LAW from engaging in any brokerage activity, unless and until he/she is authorized to do so by the New Jersey Real Estate Commission.PRINT Full Legal Name of Employing Broker, or Broker of Record, or Holder of Power of Attorney filed with the New Jersey Real Estate Commission.SIGNATURE of Full Legal Name of Employing Broker, or Broker of Record, or Holder of Power of Attorney filed with the New Jersey Real Estate Commission.DATE (mm/dd/yy) ................
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