Anda di halaman 1dari 1

PRLD.0017.

02

Housing and Land Use Regulatory Board


Northern Tagalog Region Field Office
3rd Flr., Insular Life Building
Dolores St.,San Fernando, Pampanga

APPLICATION FOR REGISTRATION OF REAL ESTATE BROKER


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 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