Licence Details Licence Number: Expiry Date: Applicant Details Surname: Title: Given Name(s): Other Names: Date of Birth: Place of Birth: Postal Address and Contact Details Unit/Building Number: Street Number: Street Name: Suburb: State: Postcode: Country: Telephone: Mobile: Fax Number: Email: Employer Details (only to be completed if you are currently employed by a licensed Real Estate / Business Agent in the NT) Name of Employer: Licence Number: Unit/Building Number: Street Number: Street Name: Suburb: State: Postcode: Country: Telephone: Mobile: Fax Number: Employer Declaration Employer declares that applicant is employed in their organisation. Employer certifies that they have read applicant's disclosures. Date Employer Signed: Employer Signature …………………….. Disclosures 1. Have you been found guilty (whether or not in the Territory) of an offence that Yes No involves dishonesty or violence or an offence against the Misuse of Drugs Act or the Kava Management Act in the past 12 months? (If yes, please provide relevant details) 2. Are you an undischarged bankrupt or have you applied to take the benefit of any law Yes No for the relief of bankrupt or insolvent debtors, compounded with creditors or made an assignment of your remuneration for their benefit in the past 12 months? (If yes, please provide relevant details) 3. Are you mentally incapable of performing duties as an agent’s representative? Yes No (If yes, please provide relevant details)
Licence Details Licence Number: Expiry Date: Applicant Details Surname: Title: Given Name(s): Other Names: Date of Birth: Place of Birth: Postal Address and Contact Details Unit/Building Number: Street Number: Street Name: Suburb: State: Postcode: Country: Telephone: Mobile: Fax Number: Email: Employer Details (only to be completed if you are currently employed by a licensed Real Estate / Business Agent in the NT) Name of Employer: Licence Number: Unit/Building Number: Street Number: Street Name: Suburb: State: Postcode: Country: Telephone: Mobile: Fax Number: Employer Declaration Employer declares that applicant is employed in their organisation. Employer certifies that they have read applicant's disclosures. Date Employer Signed: Employer Signature …………………….. Disclosures 1. Have you been found guilty (whether or not in the Territory) of an offence that involves dishonesty or violence or an offence against the Misuse of Drugs Act or the Kava Management Act in the past 12 months? Yes No (If yes, please provide relevant details) 2. Are you an undischarged bankrupt or have you applied to take the benefit of any law for the relief of bankrupt or insolvent debtors, compounded with creditors or made an assignment of your remuneration for their benefit in the past 12 months? Yes No (If yes, please provide relevant details) 3. Are you mentally incapable of performing duties as an agent’s representative? Yes No (If yes, please provide relevant details)
registration-renewal-form-agents-representative.docx