License Information
DRE license number
Name as shown on license
License expiration date
License type: Broker Sales
Personal Information
Name as you wish it to appear on our records
Social Security number
Driver's license number
If transferring membership, list current Board or Association
Firm Information
Firm name
Street address
Suite number
City
State
Zip code
Phone number
Fax number
Voice mail number
Is this your principal place of business? Yes No
If no, enter your principal place of business
List any other dba's
Home Information
Where would you like to receive your mail? Home Business
Disciplinary Record
Have you ever been disciplined by a local Board or Association of REALTORS? Yes No
Have you ever been disciplined by the California Department of Real Estate? Yes No
If so, please provide details, case numbers, and dates
Organizational Information
List all licensees (name, type of license, license number) under your Broker's license.
Position: Sole proprietor General partner Corporate officer Non-principal
Sole proprietors, general partners, or corporate officers must answer these questions
Are you subject to any pending bankruptcy proceedings? Yes No
Have you been adjudged bankrupt within the last three (3) years? Yes No
Do you have any record of official sanctions by a court or other lawful authority within the past three (3) years for...
Civil rights laws? Yes No
Real estate licensing laws? Yes No
Other laws prohibiting unprofessional conduct? Yes No
Have you ever been disciplined by the D.R.E? Yes No
Have you ever been disciplined by any other Association or Board of REALTORS? Yes No
If you answered yes to any of these questions, please provide details and attach copies of sanctions
Other memberships
List all Boards or Associations of REALTORS to which you now belong as a member
List all Boards or Associations of REALTORS to which you have belonged in the past
