CHH Certified Realtor Application Form

Conscious Healthy Home Realtor Certification™

Registration Form
SECTION 1: PERSONAL INFORMATION
Full Legal Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Real Estate License Number*
Licensed?*

YesNo
If "Yes", in which state? If "No", please type "N/A"*
Real Estate License Expiration Date*
Referred by / Referral Code*
SECTION 2: CONTACT INFORMATION
Business Name
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Which course are you registering for*

LIVE event in The Woodlands, TX (Date/Time to be announced; 4 hours of TREC-approved CE)LIVE event in Austin, TX (Date/Time to be announced; 4 hours of TREC-approved CE)Online event (4 week commitment @1hr/week; No CE credit)
Emergency Contacts*
SECTION 3: PROFESSIONAL EXPERIENCE
Primary Market Area*
Years in Real Estate*
Number of Transactions (past 12 months)*
Areas of Specialization*
Professional Designations Held*
SECTION 4: INSURANCE INFORMATION
Do you have General Liability Coverage*

YesNo
Do you have Professional Liability Coverage*

YesNo
SECTION 5: BACKGROUND VERIFICATION

Please answer all questions. If you answer "Yes" to any question, provide a detailed explanation on a separate sheet.
Has your real estate license ever been suspended or revoked?*

YesNo
Have you ever been subject to disciplinary action by a real estate board?*

YesNo
Have you ever been convicted of a felony or misdemeanor related to real estate practice?*

YesNo
Have you had any customer complaints filed against you in the past 5 years?*

YesNo
Have you ever filed for bankruptcy or had any liens placed against you?*

YesNo
SECTION 6: CODE OF ETHICS ACKNOWLEDGMENT

I hereby certify if my application is accepted, I will read and acknowledge my understanding of the Conscious Health Home Certified Realtor Code of Ethics.
I will agree uphold all provisions of the Code of Ethics in my professional practice*

AgreeDisagree
I will complete required annual Code of Ethics attestation with certification renewal*

AgreeDisagree
I understand that any certification earned can be revoked for Code of Ethics or other program violations*

AgreeDisagree
I will maintain documentation of ethical business practices*

AgreeDisagree
I will read and understand the Certification Program Agreement*

AgreeDisagree
I will acknowledge that the Code of Ethics is incorporated into the Certification Agreement*

AgreeDisagree
I certify that all information provided in this application is true and correct*

AgreeDisagree
I authorize verification of all information provided*

AgreeDisagree
I understand that certification fees are non-refundable*

AgreeDisagree
Privacy Notice: All information provided will be kept confidential and used solely for certification purposes.
I understand that photographs and video may be taken and my image may appear in marketing material on social media or websites.
By signature below, I confirm all information provided is true and correct.
Signature*
Date

MonthDayYear
Date
Should be Empty:

Conscious Healthy Home Realtor Certification™

SECTION 1: PERSONAL INFORMATION

SECTION 2: CONTACT INFORMATION

SECTION 3: PROFESSIONAL EXPERIENCE

SECTION 4: INSURANCE INFORMATION

SECTION 5: BACKGROUND VERIFICATION

SECTION 6: CODE OF ETHICS ACKNOWLEDGMENT