NORTH CAROLINAREAL ESTATE COMMISSION

P.O. Box 17100Raleigh, NC 27619

919.875.3700

Real Estate Prelicensing, Postlicensing,or Update CourseInstructor

Applicationfor Original Approval (REC 3.76)

Refer to Commission Rule 58H.0302: Application and Criteria for Original Prelicensing, Postlicensing, or Update Course Instructor Approval.

Note: If you wish to reinstate instructor approval, please contact the Education & Licensing Division to discuss requirements.

PLEASE REVIEW THE APPROPRIATE RULE PRIOR TO COMPLETING THIS FORM.

  1. Full Legal Name: Click here to enter text.
  1. NC Real Estate Broker License #:Click here to enter text.
  1. Instructor Number assigned by NC Real Estate Commission:Click here to enter text.

(If you do not have an Instructor Number, insert N/A.)

  1. Preferred Email Address for Education Division Use:Click here to enter text.
  1. Preferred Mailing Address

Street Address: Click here to enter text.

City: Click here to enter text.

State: Click here to enter text.

9-Digit Zip:Click here to enter text.

Telephone:Click here to enter text.

  1. Residence Address(if different from above)

Street Address: Click here to enter text.

City: Click here to enter text.

State: Click here to enter text.

9-Digit Zip:Click here to enter text.

Telephone:Click here to enter text.

  1. Approval Requested- Check all that apply.

☐Prelicensing/Postlicensinginstructor

☐Update instructor

  1. Real Estate Brokerage and/or Teaching Experience Select all that apply and attach information as required perCommission Rule 58H .0302(b).

☐Real Estate Brokerage Experience

An instructor applicant may qualify with two (2) yearsactive full-time experience in real estate

brokerage, including at least one year of brokerage experience in North Carolina, within the previous seven (7) years.

Required Documentation: Provide details of all brokerage within the previous seven (7) years.

Attach additional page(s) if necessary.

Name of Employer: Click here to enter text.

Location (city, state): Click here to enter text.

Dates of Employment – From (mo/yr)-To (mo/yr): Click here to enter text.

Supervisor or BIC Name: Click here to enter text.

Supervisor / BIC Telephone #: Click here to enter text.

Job Title: Click here to enter text.

Average Hours per Week Devoted to Brokerage: Click here to enter text.

Areas of Practice and Percentage of Time Devoted to Each: Click here to enter text.

Approximate # of Total Transactions / Overall Sales Volume: Click here to enter text.

Additional Details regarding this Job: Click here to enter text.

Name of Employer: Click here to enter text.

Location (city, state): Click here to enter text.

Dates of Employment – From (mo/yr)-To (mo/yr): Click here to enter text.

Supervisor or BIC Name: Click here to enter text.

Supervisor / BIC Telephone #: Click here to enter text.

Job Title: Click here to enter text.

Average Hours per Week Devoted to Brokerage: Click here to enter text.

Areas of Practice and Percentage of Time Devoted to Each: Click here to enter text.

Approximate # of Total Transactions / Overall Sales Volume: Click here to enter text.

Additional Details regarding this Job: Click here to enter text.

Name of Employer: Click here to enter text.

Location (city, state): Click here to enter text.

Dates of Employment – From (mo/yr)-To (mo/yr): Click here to enter text.

Supervisor or BIC Name: Click here to enter text.

Supervisor / BIC Telephone #: Click here to enter text.

Job Title: Click here to enter text.

Average Hours per Week Devoted to Brokerage: Click here to enter text.

Areas of Practice and Percentage of Time Devoted to Each: Click here to enter text.

Approximate # of Total Transactions / Overall Sales Volume: Click here to enter text.

Additional Details regarding this Job: Click here to enter text.

☐Secondary or Post-Secondary-Level Teaching Experience

An instructor applicant may qualify with three (3)years of instructor experience at a

secondary or post-secondary level.

Required Documentation: Provide details of all teaching experience at the secondary or post-secondary level within the previous seven (7) years.

☐Approval as a Prelicensing or Postlicensing Instructor in Another Jurisdiction

An instructor applicant may also qualify based on teachingexperience gained through

Prelicensing or Postlicensing instructor approval in another jurisdiction.

Required Documentation: Submitcertification of such approvalheld within the previous seven (7) years.

  1. Character

(a)Criminal Offenses:

Have you ever been convicted of any criminal offense (felony or misdemeanor) or is there any criminal charge now pending against you?You must report all offenses for driving while impaired and any other offenses classified as “criminal traffic” offenses. Exclude only minor traffic “infractions”.

☐YES ☐NO

If “YES”, provide a detailed written explanation in your own words describing the circumstances for each conviction/pending charge. For a conviction, you must attach a copy of the court order or criminal record report showing disposition of the case. The Commission reserves the right to require the applicant to provide additional information, including a criminal record report from an agency acceptable to the Commission.

(b)Professional License Disciplinary Action:

Have you ever been denied a real estate or other professional license or been disciplined by an occupational licensing agency (license suspended, revoked, surrendered, reprimanded, censured, or otherwise disciplined) in N.C. or elsewhere; or are there currently any complaints pending against you in connection with any professional license that you hold?

☐YES ☐NO

If “YES”, provide a detailed written explanation in your own words describing the circumstances for each disciplinary action and attach a copy of the licensing agency’s order (if the disciplining agency was other than the NC Real Estate Commission).

  1. Real Estate Licensing History - Attach additional page(s) if necessary.

State / License # / License Type
(salesperson / broker) / From (mo/yr) - To (mo/yr) / Is this License Active?
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐YES ☐NO
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐YES ☐NO
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐YES ☐NO
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐YES ☐NO
  1. College Education - PerCommission Rule 58H .0302(b), an instructor applicant must have completed 60 hours of college-level education at an institution whose accreditation is recognized by the U.S. Department of Education. Attach additional page(s) if necessary.

Name of School / Location
(city, state) / Dates Attended: From (mo/yr) - To (mo/yr) / Major / Degree Awarded
OR Semester/Quarter Hours Completed
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
  1. Instructor Video Recording - PerCommission Rule 58H .0302(c), an instructor applicant must submit with the application a digital video recording of the applicant teaching a 50-minute block of a single topic in a Prelicensing, Postlicensing, or Update course that demonstrates the ability to teach the subject in a manner consistent with the course materials.

☐Video recording enclosed.

The video recording must meet the conditions set forth in Commission Rule 58H .0305. Review the rule and ensure that all conditions are met prior to submission. Also, applicants are strongly encouraged to attend the New Pre/PostlicensingInstructor Seminar prior to recording the video.

  1. Date of video recording? Click here to enter a date.
  2. Video format submitted?Choose an item.
  3. Course being taught?Choose an item.
  4. Subject matter of recording? Click here to enter text.

☐I am exempt from this requirement because I am already a Commission-approved instructor.

☐I am exempt from this requirement because I hold a DREI or equivalent instructor certification.

The certification I hold is Click here to enter text.

  1. New Pre/PostlicensingInstructorSeminar - Commission Rule 58H.0302(e) requires applicants to complete the Commission’s New Pre/PostlicensingInstructor Seminar prior to teaching any Prelicensing or Postlicensing course. Indicate below how you have satisfied or intend to satisfy this requirement:

☐I attended the New Pre/PostlicensingInstructor Seminar on: Click here to enter a date..

☐I will attend the New Pre/PostlicensingInstructor Seminar prior to teaching any Prelicensing or Postlicensing course.

☐N/A. I am not applying to be a Pre/PostlicensingInstructor.

  1. Update Instructor Seminar - Update instructor approval will be issued on inactive status untilthe instructor has completed the Commission’s annualUpdate Instructor Seminar for the current licensing period.PerCommission Rule 58H.0302(f), the instructor will be unable to teach any Update courses while inactive.
  1. Signature and Certification of Applicant. ALL applicants for original approval must sign the application.

I certify that the information provided in this application is accurate to the best of my knowledge.

I understand that any omission, inaccuracy, or failure to make full disclosure constitutes grounds for denial or withdrawal of approval to teach the Commission’s Prelicensing,Postlicensing, orUpdate courses and may constitute grounds for disciplinary action against me in connection with any other license or approval I hold that was issued by the N.C. Real Estate Commission.

Signature / Date

REC 3.76

Page 1 of 5 REV 7/2017