(Revised 03/15) / Membership Camping Resort
Sales Person or Contract-Broker Registration Application / This space reserved for office use.
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11.Has your license as a real estate broker or salesperson in this or any other state ever been revoked or suspended?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
Form #3102