Please fill in the appropriate information below:

Fields designated with an asterisk (*) signify a MANDATORY field.

A. PERSONAL INFORMATION
Name*	Mr. Mrs. Ms.       *Last Name    *First Name    Middle Name
Date of Birth*	2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Email Address*	(Email is the Saskatchewan Real Estate Commission's primary method of communication)
Residential Address*	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon -states- Alabama Arizona Arkansas Alaska California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   *Address *City *Province/State *Postal Code/Zip
Mailing Address if different from Res. Address	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon -states- Alabama Arizona Arkansas Alaska California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Address    City    Province/State    Postal Code/Zip
Home Phone #*	Cell Phone #*       Fax #       ↑ You MUST provide at least ONE phone number ↑
B. INFORMATION RESPECTING PREVIOUS/CURRENT JURISDICTION
Are you currently licensed/registered?*     YesNo If the answer is NO, are you eligible for re-licensing/registration with no additional requirements?*     YesNo If the answer is NO, what requirement(s) must be completed prior to becoming eligible re-licensing/registration?*
Please detail your most recent licensing/registration details below: From (mm/dd/yyyy)   To (mm/dd/yyyy)   Province   Class of License/Registration 1.        Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon    2.        Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon    3.        Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon    4.        Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon    5.        Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
NOTE: In order for the Saskatchewan Real Estate Commission to consider your eligibility for licensing/registration reciprocity, you must instruct the regulatory bodies in the jurisdictions listed above to send your licensing/registration history(ies) directly to the Saskatchewan Real Estate Commission (info@srec.ca).
C. AUTHORIZATION & ACKNOWLEDGEMENT
I authorize the Saskatchewan Real Estate Commission to verify any information pursuant to this document from any source. I acknowledge that I am responsible for any costs incurred for such verification. I consent to the Saskatchewan Real Estate Commission's collection, use and disclosure of my personal information for licensing/registration and other regulatory purposes under The Real Estate Act and The Personal Information Protection Act.
D. AFFIDAVIT
I acknowledge that making a false statement on this affidavit may constitute a criminal offence punishable by law, resulting in the refusal, suspension or cancellation of a license/registration and/or be considered conduct deserving of sanction pursuant to The Real Estate Act, its regulations or Bylaws.