Personal Information Form

	Saskatchewan Real Estate Commission 104 - 210 Wellman Crescent, Saskatoon, Saskatchewan S7T 0J1 Bus. (306)374-5233 * Toll Free 1-877-700-5233 For more information about the complaint process, please visit our website: www.srec.ca
Personal Information Form

A. PERSONAL INFORMATION

Name *

Date of Birth *

Email Address *

(Email is the Saskatchewan Real Estate Commission's primary method of communication)

Residential Address *

Mailing Address

Phone # *

(You MUST provide at least ONE phone number)

B. INFORMATION RESPECTING PREVIOUS/CURRENT JURISDICTION

Are you currently licensed/registered? *

Yes

If the answer is NO, are you eligible for re-licensing/registration with no additional requirements? *

Yes

If the answer is NO, what requirement(s) must be completed prior to becoming eligible re-licensing/registration? *

Please list your licensing/registration details below:

From

Province

Class of License/Registration

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.