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REAL ESTATE INDIVIDUAL OR ASSOCIATE BROKER …

1 of 3 Bureau of Professional Licensing PO Box 30670 Lansing, MI 48909 Telephone: (517) 241-9288 REAL ESTATE INDIVIDUAL OR ASSOCIATE BROKER LICENSE OR RELICENSURE APPLICATION Authority: 1980 PA 299, MCL , and 42 USC 654 Name (First, Middle, Last) Date of Birth Social Security Number Address City State Zip Code Permanent ID Number (Relicensure only) Telephone Number E-mail Address If you answer yes to this question, you must complete and submit the Request for Conviction History form AND submit documentation which shows at the current time you have the ability to, and are likely to, serve the public in a fair, honest, and open manner, that you are rehabilitated, or that the substance of the former offense is not reasonably related to the occupation or profession for which you are seeking a license.

2 of 3 New Employing Broker Name (This does not apply to Individual Broker applicants.) Employing Broker Permanent I.D. Number (if applicable)

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