Texas



|Form 3102 |[pic] |This space reserved for office use. |

|(Revised 03/15) |Membership Camping Resort | |

| |Sales Person or Contract-Broker Registration Application | |

|Submit to: | | |

|Secretary of State | | |

|Registrations Unit | | |

|P.O. Box 13550 | | |

|Austin, TX 78711-3550 | | |

|512 475-0775 | | |

|FAX: 512 475-2815 | | |

|Filing Fee: $50.00 | | |

I am applying for: (please circle one) SALESPERSON CONTRACT-BROKER

1. Name of Applicant:__________________________________________________________________

2. Residence Address:_________________________________________________________________

____________________________________________________________________________________

3. Telephone Numbers: Home ( )__________________ Business ( )___________________

4. Business Address:____________________________________________________________________

____________________________________________________________________________________

5. Name of Employer: (if applicable)_____________________________________________________

6. Address of Employer:(if applicable)___________________________________________________

_____________________________________________________________________________________

7. Have you ever been convicted of a felony or a misdemeanor involving moral turpitude?

_________ Yes _________No

8. If you answered yes to Question 7, describe the nature of the crime, when and where it was committed, and the disposition of the conviction.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

9. Have you been refused a real estate broker's or salesperson's license, or any other occupation license in this or any other state?

________Yes ________ No

10. If you answered yes to Question 9, explain fully the circumstances of the refusal.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

11. Has your license as a real estate broker or salesperson in this or any other state ever been revoked or suspended?

_______ Yes ________ No

12. If you answered yes to Question 11, explain fully the circumstances of the denial or suspension.

____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I certify (or declare), under penalty of perjury, that I have read the foregoing registration and that all the answers are true and correct. Further, I understand and agree that any misstatements of a material fact in this application may result in suspension or revocation of my registration with the State of Texas.

____________________________________________

Signature of Applicant

************************************************************

RETURN THIS APPLICATION WITH THE $50.00 FILING FEE TO:

SECRETARY OF STATE

REGISTRATIONS UNIT

P. O. BOX 13550

AUSTIN, TX 78711-3550

FOR DELIVERY:

JAMES EARL RUDDER OFFICE BUILDING

1019 BRAZOS

AUSTIN, TX 78701

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