Real Estate Application

Social Security Number (No dashes) *

Middle Name or Initial *

Street Number, Street Name, Apartment / Unit # *

City, State and Zip Code *

Street Number, Street Name Apartment . Unit # *

City State Zip Code *

Choose One *

Female Male

Birthdate (Month / Day / Year) *

Are you applying for a license as a Georgia resident? *

Yes No

Are you a Veteran who served at least 90 days active duty during war time? *

Yes No

Have you ever been licensed as a salesperson or broker in another state? If yes, bring a Certificate of History from each state, no older than one year, with you to the testing center *

Yes No

If you answered YES,what state? *

If YES, under what name? *

Have you ever held or do you hold a real esate license in Georgia? *

Yes No

If YES, under what name? *

Are you a high school graduate or hold a General Education Certificate (GED)? If your answer to this question is NO, bring proof of educational equivalency to the testing center with you. *

Yes No

Have you ever been convicted of, Pled Nolo Contendere or been granted first offender treatment upon being charged with (1) any criminal offense other than a traffic violation or (2) any violation that involved driving under the influence of alchol or drugs, homocide, or feticide by vehicle , fleeing the scene of an accident, attempting to elude an officer or impersonating an officer? *

Yes No

Have you ever been disciplined by the Georgia Real Estate Commission or any other State or Federal Licensing Agencyor authority which regulates any profession? *

Yes No

Are there any criminal charges or licensing disciplinary proceedings pending against you at this time? *

Yes No

Are you currently required by any court, administrative or contempt order to make child support? *

Yes No

If applying for a Brokers license, how many years have you been actively licensed as Salesperson? *

If applying for a Broker's License, how many years have you been actively licensed as Broker? *

If applying for a Broker's License, how many years have you bee n actively licensed as a COmmunity Asociation Manager? *

Real Estate Career & Developement Center

Applicant Information:

Residence Address:

Mailing Address: