Real Estate License Compliance Acknowledgment Form
Please complete this form to confirm your compliance with real estate licensing requirements.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Employment Status
*
Please Select
Active Real Estate Agent
Inactive/On Hold
Retired
Other
Are you currently in good standing with the real estate licensing authority?
*
Yes
No
Date of Most Recent Compliance Training or Continuing Education
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been subject to any disciplinary action in the past 12 months?
*
No
Yes (please explain below)
If yes, please briefly explain the disciplinary action.
Additional Comments (optional)
By submitting this form, I acknowledge that the information provided is accurate and that I am in compliance with all applicable real estate licensing requirements.
*
I acknowledge and attest to the above statement.
Submit
Should be Empty: