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Region IV-A

APPLICATION FOR REGISTRATION OF REAL ESTATE SALESPERSON


Original ( ) Renewal ( )
Pursuant to Sections 11 and 12 of Presidential Decree No. 957,
as implemented by Board Resolution No. 922, Series of 2014

Name of Applicant:

Civil Status: Age: Name of Spouse:


Office Address:

Tel. No.:
Branch Office Address:
Tel. No.:
Residence Address:
Tel. No.:
Year Last Registered (for renewal only)

*Attached herewith are the following:


[ ] Two (2) recent 2 X 2 color photo;
[ ] Photocopy of valid PRC-issued Certificate of Registration and PRC-issued
Professional Identification Card (Originals thereof to be presented upon filing,
for comparison as faithful reproduction);
[ ] Photocopy Letter of Engagement / Employment signed by an HLURB-registered
Dealer or Broker;
[ ] Photocopy of the Bond or Security (Original copy to be presented upon filing,
for comparison as faithful reproduction); and
[ ] Photocopy of the Official Receipt.

Have you ever been convicted of any crime involving a penalty of more than six (6) months
imprisonment? If yes, state the nature:

Printed Name and Signature

,
Place Date

T.I.N.

*APPLICATION WITH INCOMPLETE REQUIREMENTS WILL NOT BE ACCEPTED FOR PROCESSING

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