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PRLD.0017.

02

Housing and Land Use Regulatory Board


Expanded National Capital Region Field Office
6th Floor, Sunnymede IT Center,
1614 Quezon Avenue, South Triangle, Quezon City

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

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