REQUEST FOR CERTIFICATE OF LICENSE HISTORY

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STATE REAL ESTATE COMMISSION PO Box 2649 Harrisburg PA 17105-2649

Phone Number: 717-783-3658 dos.estate

Overnight Mailing Address: State Real Estate Commission

2601 N Third Street Harrisburg PA 17110

REQUEST FOR CERTIFICATE OF LICENSE HISTORY

The Certificate of License History includes the original date of licensure, current status, how the license was obtained, and if any disciplinary action exists. It also indicates the education credits and test scores needed for your license classification.

Return this completed form along with a $40.00 check or money order payable to the Commonwealth of Pennsylvania." NOTE: There is a $20.00 charge for all return checks regardless of the reason for

non-payment.

LICENSEE'S INFORMATION

Licensee's Last Name:

First:

Middle:

License #

Social Security #

Street:

Licensee's Address: City:

State:

Zip:

Select your delivery method below. Note ? You can only select one delivery method per request.

Mailed

MAILING INFORMATION: Provide the mailing address for the location where you wish this mailed. Name:

Street:

Mailing Address: City:

State:

Zip:

Emailed

EMAILING INFORMATION: PLEASE NOTE: E-MAILED COPIES OF YOUR CERTIFICATE OF LICENSE HISTORY DO NOT INCLUDE A RAISED SEAL ON THE DOCUMENT. IF YOU REQUIRE A RAISED SEAL, YOU MUST REQUEST THE DOCUMENT TO BE RECEIVED BY MAIL (ABOVE).

Provide the name and email address of the party you wish this emailed. Recipient's Name:

Recipient's Email:

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