Application for Original Education Provider Certification

An image of the North Carolin Real Estate Seal.

Requirements for certification and operation of an education provider are defined in General Statute 93A-Artcle 3 and 21 NCAC Chapter 58 H.0202 and should be read prior to completing this form.
If applicable, Consent to Service Process and Pleadings (REC 1.03)
All of the following items MUST be submitted by a non-public applicant:
Education Provider Policies and Procedures Disclosure (PPD).
Non-refundable Application Fee of $200 required for each non-public proposed location.
Payment may be made with a Visa, MasterCard, American Express, Discover, or valid PayPal account.

PLEASE REVIEW THE STATUTE AND RULES PRIOR TO COMPLETING THIS FORM

Is the Education Provider "Public" per GS 93A-32(2) ? *

Indicate the type of business structure*

Specify "Other" Business Structure*

Secretary of State Identification # (SOSID)*

Legal Name of Education Provider*

Advertised Name of Education Provider (If advertised name differs from name of Education Provider, Assumed Name Certificate must be registered with the county Register of Deeds.)

Administrative/Principal Office of Education Provider

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Mailing Address

City

State

9-Digit Zipcode Lookup

Principal Office Phone*

Principal Office Email*

Website*

Education Director

First Name*

Middle Name

Last Name*

Broker License # (if applicable)

Director's Phone*

Director's Email Address*

Is this director a permanent employee?*

Director's Title*

Courses To Be Offered

Note: Certification as an Education Provider authorizes the EP to conduct real estate courses. However, prior to advertising or offering any courses, the EP must submit form REC 7.33 – Approval of a Real Estate Education Course in order to obtain approval for each course to be offered.

Broker Prelicensing Course

Will this Education Provider be conducting this course?* There is a $40 fee.

Broker Postlicensing Courses

Will the Education Provider be conducting theses courses?* There is a $40 per course fee.

What Postlicensing Courses will the Education Provider be conducting? (30 hours minimum, per course, Select all that apply)*

Post 301-Broker Relationships & Responsibilities

Post 302-Contracts & Closing

Post 303-NC Law, Rules, and Legal Concepts

Continuing Education Courses

Will this Education Provider be offering Update courses?* The $100 materials fee will be included when submitting REC 7.34 Application for Approval to Offer the Commission’s Update Courses In Person or via Synchronous Distance Learning.

Will this Education Provider be offering Elective courses?* Course fee will be included when submitting REC 7.33 Application for Approval of a Real Estate Education Course.

Provider Locations

How many provider locations is the Education Provider proposing?*
There is a $200 per location fee.

Administrative/Principal Location*

ADA Compliant*

Phone # for this location*

Physical Address

City

State

9-Digit Zipcode Lookup

County*

Location #2*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #3*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #4*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #5*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #6*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #7*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #8*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #9*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Location #10*

ADA Compliant*

Phone # for this location*

Physical Address*

City*

State*

9-Digit Zipcode Lookup*

County*

Education Provider Policies & Procedures Disclosure (PPD)

Upload a copy of the PPD including all items on the PPD checklist.*
*Accepted File Types: .txt .pdf .docx .doc
*Max individual file upload size is 2Mbs

Select your file

File name

Consent to Service

If applicable, upload a copy of the Consent to Service Process and Pleadings (REC 1.03).*
This requirement applies ONLY to Foreign (Out-of-State) Corporations, Limited Liability Companies, and Limited Partnerships.
*Accepted File Types: .txt .pdf .docx .doc
*Max individual file upload size is 2Mbs

Select your file

File name

Additional Documentation

Attach any additional documentation that supports this application.
*Accepted File Types: .txt .pdf .docx .doc
*Max individual file upload size is 2Mbs

Select your file

File name

Select your file

File name

EMPLOYEE MISCLASSIFICATION

Read the Public Notice Statement. Click the box to certify that you have read the statement, and select Yes or No in response to the question regarding investigations. If you select Yes, you will be required to provide information regarding the case(s). If you have questions regarding this section, please direct them to the North Carolina Industrial Commission. Contact information is provided on the page.

As required by the NC state legislature in NCGS § 143-765, effective January 1, 2018, in order to apply for or renew an occupational license, permit, or certification, the applicant must certify that they have read and understand the public notice statement from the Employee Classification Section of the State Industrial Commission and must disclose any investigations for employee misclassification.

Public Notice Statement
required by N.C. Gen. Stat. § 143-764(a)(5), effective December 31,2017

Any worker who is defined as an employee by N.C. Gen. Stat. §§ 95-25.2(4)(NC Department Of Labor), 143-762(a)(3)(Employee Fair Classification Act), 96-1(b)(10)(Employment Security Act), 97-2(2)(Workers’ Compensation Act), or 105-163.1(4)(Withholding; Estimated Income Tax for Individuals) shall be treated as an employee unless the individual is an independent contractor. Any employee who believes that the employee has been misclassified as an independent contractor by the employee’s employer may report the suspected misclassification to the Employee Classification Section within the North Carolina Industrial Commission.

Employee Classification Section
North Carolina Industrial Commission
1233 Mail Service Center
Raleigh, NC 27699-1233
Telephone: (919) 807-2582
Fax: (919)715-0282
Email: emp.classification@ic.nc.gov

Employee misclassification is defined as avoiding tax liabilities and other obligations imposed by Chapter 95, 96, 97, 105, or 143 of the North Carolina General Statutes by misclassifying an employee as an independent contractor.N.C. Gen. Stat. § 143-762(5)

I certify that I have read and understand the Public Notice Statement.*

Since your last license renewal [or since the date of initial licensure if this is your first renewal], have you been the subject of an investigation for employment misclassification by a government entity?*

If YES, please provide the investigating entity, case or file number, if known, and the results of the investigation.*
Max 1900 characters

Application Fees

The classroom location fee must be paid for each proposed classroom location; however, the course fees need only be paid once for each Education Provider. [See Rule 58H .0202 ] All application fees are nonrefundable.

Purchase Request	Amount Due
Provider Location(s):$200 per location:	$0
Conduct Broker Prelicensing Course ($40):	$0
Conduct Broker Postlicensing Courses ($40 x 3 = $120):	$0
TOTAL FEE:	$200

Form Processing

Any Education Provider Certifications, Branch Locations, and/or courses approved now for the current license year must be renewed between May 15 - June 30 to assure continuous approval into the license year beginning July 1.

Are you requesting approval of this Certification for USE prior to July 1?*

Signature & Certification

I certify that I have read the foregoing application and that the information provided therein is true and correct to the best of my knowledge and belief. I also certify that all courses conducted by this education provider shall be conducted in compliance with General Statute 93A-Article 3 and the Commission rules of Subchapter 58H.

Signature Required*

(Type your name)

Title

Date Signed

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