Pathologist Assistant

ARKANSAS REAL ESTATE COMMISSION

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

Little Rock, AR 72201-47 40

Phone: 501-***-**** Fax: 501-***-****

www.arec.arkansas.gov

****.***********@********.***

Checklist for Arkansas Residents Applying for a Real Estate License: o Completed, notarized application.

o Cashier’s check or signed money order in the amount of $50, payable to AREC.

o Copy of your ID or birth certificate

o Background Check Acknowledgment Form

o Signed copy of 60-hour Pre-License Education Certificate o If you have ever been licensed in another state, you must submit an Original License History from your state of residence and any other state you are licensed or have been licensed.

o Broker candidates must submit a broker experience form. IMPORTANT NOTES TO REMEMBER:

• Make sure email address is legibly printed on the application. Once application is fully processed, the candidate will receive an email from AREC with instructions on completing the background check.

• After passing the exam, applicants MUST submit their score report, licensing fee, & accompanying documents to AREC NO LATER THAN 90 Days after passage of the exam. By statute, the deadline is 90 calendar days, and no extensions are granted.

AREC 06/2023

ARKANSAS REAL ESTATE COMMISSION (AREC)

612 South Summit Street, Little Rock, AR 72201-4740 phone: 501-***-**** fax: 501-***-****

APPLICATION FOR REAL ESTATE LICENSE EXAMINATION

Check one: Q Salesperson Q Broker

Instructions: This application must be completed, signed and notarized. Each question must be answered and the necessary documentation and fees attached or the application will be returned to the applicant. 1. NAME OF APPLICANT: (as stated on driver’s license) LAST NAME FIRST MIDDLE MAIDEN

/ /

- -

2. DATE OF BIRTH MO DAY YEAR SEX M/F SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER STATE OF ISSUE RACE STATE OF BIRTH 3. MAILING ADDRESS: STREET ADDRESS (If applicable, please include the following information - Apartment/Suite/Floor #) PO BOX NUMBER CITY STATE ZIP CODE+4 DAYTIME PHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS 4. After the initiation of an investigation, hearing, or other administrative action, have you had a professional, vocational or occupational license, permit, certification or registration denied, revoked, suspended, cancelled, surrendered, or subject to any sanctions, including probation?

(If you responded Yes, provide a written report. The report should include the date of the action, name and address of the regulatory agency which has taken the action, and copies of the documents pertaining thereto. The report should also include your explanation of the circumstances which led to the action, along with any additional information you wish to submit.) YES NO

5. Have you ever been convicted of any crime other than a traffic violation? Being convicted shall include all instances in which a Plea of guilty or nolo contendere or finding of guilt is the basis for the conviction, and all proceedings in which the sentence has been deferred or suspended.

(If you responded Yes, provide a written report of the conviction which should include the date of the offense and of the conviction, the name and address of the court, the specific crime of which convicted or to which a guilty plea or nolo contendere (no contest) was entered, the fine, penalty and/or other sanctions imposed, and copies of the charging document and judgement of conviction or other disposition including probation or suspension of sentence. All requested documents and reports must be included with the application.) YES NO

IF YOU DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY. 6. Are there any pending lawsuits filed against you or have you ever had a judgement entered against you for fraud, deceit, dishonesty, misrepresentation, or conversion of property including money belonging to another in any civil proceedings?

(If you responded Yes, provide a written report which should include a complete statement of the charges and facts, together with dates, name and location of the court in which the proceedings were held or are pending.) YES NO

7. Are there any judgements against you?

(If you responded Yes, provide a written report which should include a copy of the unsatisfied judgement.) YES NO

8. Are you now licensed or have you ever been licensed in real estate in Arkansas or any other jurisdiction?

(If you responded Yes, list all such jurisdictions and provide a certified License History from the official record of all those jurisdictions except Arkansas.) YES NO

9. Are you or your spouse an active duty military member or returning military veteran? (If you responded Yes, please provide a copy of your current military identification card. Additional documentation may be necessary.) YES NO

10. A.C.A.§ 17-1-104 requires agencies that issue professional licenses to record and forward applicant’s Social Security Number to Child Support Enforcement.

For that reason, it is mandatory that an applicant for an Arkansas real estate license disclose his/her Social Security Number. Social Security Numbers will be transferred to the Arkansas Office of Child Support Enforcement for Child Support Purposes. Social Security Numbers shall not be disclosed publicly and are exempt from open records requirements of the Freedom of Information Act. Disclosure of Social Security Numbers without the consent of the individual is a Class B misdemeanor. Failure of an applicant to state his/her Social Security Number in an application for a real estate license will result in the denial of the license. ATTACH PROOF OF THE FOLLOWING:

A. Attainment of age of majority (18) (Copy of driver’s license, copy of birth certificate, or other acceptable document)

B. Successful completion of education requirements

(Original certificate(s), or certified copies, or other documentation satisfactory to the Commission) C. Successful completion of experience requirements for broker applicants

(Completion of Broker Experience Form and certified license history if experience requirement was met in another jurisdiction)

D. Background Check Acknowledgment (BCA) Form. (For completion of federal criminal record search). Non- Residents must also submit a completed fingerprint card. 28 CFR § 16.34 – Procedure to obtain change, correction, or updating of identification records. If, after viewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wish changes, corrections, or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Service (CJIS) Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency. By placing my signature below I certify that I have read each paragraph above and acknowledge each disclosure, that all information provided in this application is true and correct, and that the Arkansas Real Estate Commission may rely on its truthfulness in considering this application. I further give my consent for the Arkansas State Police and the Federal Bureau of Investigations to conduct a criminal record search and to release any results to: Arkansas Real Estate Commission, 612 South Summit Street, Little Rock, Arkansas 72201-4740 SIGNATURE DATE (MONTH/DAY/YEAR)

NO REQUEST WILL BE PROCESSED WITHOUT A NOTARIZED SIGNATURE. State of

County of

Subscribed and sworn before me, a Notary Public, in and for the

county and state aforesaid, this the day of, 20 .

NOTARY PUBLIC SIGNATURE

NOTARY SEAL

Arkansas Real Estate Commission

Mailing Address:612 S. Summit, Little Rock, AR 72201 Telephone 501-***-**** Fax 501-***-****

Website: http://www.arec.arkansas.gov

Background Acknowledgement Form

Privacy Act Statement Privacy Act of 1974, 5 USC § 552a Authority: The FBl's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBl's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBl's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Obtaining Copy: Procedures for obtaining a copy of FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.30 through 16.33 or go to the FBI website at http://www.fbi.gov/about- us/cjis/background-checks.

Change, Correction, or Updating: Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34. SIGNATURE: DATE: APPLICANT INFORMATION (Please fill out all the fields below and send to the AREC with your application): Full Name:

Social Security #:

Last First

Date of Birth:

Middle

State of Birth:

Residential Address:

Street Address City State Zip

I understand that my personal information and fingerprints submitted by agency are used to search against criminal identification records from both Arkansas Crime Information Center (ACIC) and Federal Bureau of Investigation (FBI). I hereby authorize the release of any records to the Arkansas Real Estate Commission, 612 South Summit Street, Little Rock, Arkansas, 72201-4740. I further understand ACIC and the FBI may also retain the submitted information and fingerprints as permitted by the Privacy Act of 1974, 5 USC § 552a, for routine uses beyond the principal purpose listed above.

Contact this candidate