DOS-1432 (Rev. 7/09)
PAGE 1 OF 1
FOR OFFICE
UNIQUE ID
CASH NUMBER
FEE
USE ONLY
|__|__|__|__|__|__|__|__|__|__|__|
$
NYS Department of State
DIVISION OF LICENSING SERVICES
P.O. Box 22001
Albany, NY 12201-2001
www.dos.state.ny.us
State Licensed/Certified Real Estate
Appraiser Application
I am applying for:
9 State Licensed Real Estate
9
I am upgrading my State License Real Estate Appraiser
Appraiser Assistant ($275)
Assistant License and have already taken and passed the
appropriate examination within the preceding 24 months
(you must also indicate to which category you are upgrading below).
9 State Licensed Residential
9 State Certified Residential
9 State Certified General
Real Estate Appraiser
Real Estate Appraiser
Real Estate Appraiser
($325) - Original
($325) - Original
($325) - Original
($300) - Upgrade
($300) - Upgrade
($300) - Upgrade
9 Temp Reciprocal State of
9 Reciprocal State of
($125)
($300)
PLEASE PRINT OR TYPE
LAST NAME
FIRST NAME
MIDDLE INITIAL
SUFFIX
APPLICANT’S HOME ADDRESS NUMBER AND STREET (PO BOX MAY BE ADDED TO ENSURE DELIVERY)
CITY
STATE
ZIP+4
COUNTY
BUSINESS NAME
BUSINESS ADDRESS NUMBER AND STREET (PO BOX MAY BE ADDED TO ENSURE DELIVERY)
CITY
STATE
ZIP+4
COUNTY
DAYTIME TELEPHONE NUMBER
SOCIAL SECURITY NUMBER OR FEDERAL ID NUMBER (SEE PRIVACY NOTIFICATION)
( )
E-MAIL ADDRESS
BACKGROUND QUESTIONS
YES
NO
1. Have you ever been convicted in this state or elsewhere of any criminal offense that is a
misdemeanor or a felony? (If YES, submit a written explanation giving the place, court
jurisdiction, nature of the offense, sentence and/or other disposition. You must provide a copy of
the accusatory instrument — e.g., indictment, criminal information or complaint — and a
Certificate of Disposition. If you possess or have received a Certificate of Relief from Disabilities,
Certificate of Good Conduct or Executive Pardon, you must provide a copy of same.)
. . . . . . . .
2. Are there any criminal charges (misdemeanors or felonies) pending against you in any co