Fillable CHECKLIST AND APPLICATION FOR REINSTATEMENT INSPECTOR OF STRUCTURES (Nevada Real Estate Division)

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CHECKLIST AND APPLICATION FOR REINSTATEMENT INSPECTOR OF STRUCTURES (Nevada Real Estate Division)

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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
realest@red.nv.gov * http://red.nv.gov/
Revised 6/25/2019 Page 1 of 5 Form 639
INSPECTOR OF STRUCTURES / ENERGY AUDITOR
CHECKLIST AND APPLICATION FOR REINSTATEMENT
Prior to submitting this application, be sure each question has been completely, thoroughly, and honestly answered. This
application must be signed. Fees are non-refundable. NRS/NAC 645D
APPLICATION: Complete the reinstatement form. Attach the documents listed below and the fee as follows:
REINSTATEMENT FEE: A fee of $20.00 is required in the form of a check, cashier check, money order made
payable to the Nevada Real Estate Division (NRED) or cash in exact change.
RENEWAL FEE: (These fees are additional to the reinstatement fees, if applicable.)
Inspector of Structures:
Renewal fee
$250.00
Late Penalty
$125.00 (if after midnight of the renewal date)
FINGERPRINT CARD: If your certificate has been inactive for over 12 months or longer you must submit with
the application:
1. ONE complete fingerprint card, along with a $40.25 cashier check or money order made payable to the
Department of Public Safety. Personal checks, company checks, or cash will not be accepted.
2. Verification of fingerprints taken electronically by an approved vendor. See Form 619 for list of vendors and
their addresses.
NON-US CITIZENS: Please provide proof of eligibility to work. Copies may be enlarged.
NON-RESIDENTS: Residents of any state other than Nevada must complete the Consent to Service of Process
form on page 4. Nevada residents do not attach page 4.
EDUCATION: (Inspector of Structures Only) Provide certificates of completed continuing education (CE) courses
approved by the Real Estate Division.
1. If renewing on time, 20 hours of CE courses including a minimum of 3 hours of safety as designated by Nevada
law is required.
2. If renewing more than 60 days following certificate expiration date, 30 hours of CE are required.
INSURANCE: Provide proof of current insurance coverage as required by Nevada law. The inspector’s name must
appear on the proof of insurance, even if the insurance policy is issued in the name of a business.
1. Errors and omissions, minimum coverage $100,000.
2. General liability, minimum coverage $100,000.
FINGERPRINT BACKGROUND WAIVER: Complete the Nevada Department of Public Safety waiver form
attached to this reinstatement form.
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
realest@red.nv.gov * http://red.nv.gov/
Revised 6/25/2019 Page 2 of 5 Form 639
Inspector of Structures / Energy Auditor
APPLICATION FOR REINSTATEMENT
Only information deemed by law to be confidential shall be confidential (SSN, exam, results, background
investigation results). Most information provided by an applicant for certification is public information
and must be provided upon request. By policy, the Nevada Real Estate Division shall post (via the web
site) and sell certificate holder lists which include the inspector’s name, business address (even if same as
home address), and business telephone number. (NRS 645D.135)
Certificate/License Number:
Date:
1. Name of certificate/license
holder:
First
Last
Home address:
No. & Street
City
State
Zip Code
Full mailing address: (if applicable)
Phone:______________________________ Cell:_________________________
Email:_____________________________________________________________________
2. If a corporation or fictitious name is registered, please attach a copy of the registration and list of officers filed
with the Nevada Secretary of State or Clark County Clerks office. Please list the business name and address of the
principal office below: (Not required if working from home)
Business name:
Business address:
No. & Street
City
State
Zip Code
Business phone:
Email address:
Fax:_____________________
OFFICE USE ONLY: Receipt#___________________
Processor___________________
Date_______________________
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
realest@red.nv.gov * http://red.nv.gov/
Revised 6/25/2019 Page 3 of 5 Form 639
3. If your answer to any of the below is YES attach the order of the court or agency which was rendered as a result of the
proceedings. Give full details, including the administrative agency, court, title of the proceeding, disposition and any other
pertinent information on an attached sheet. If less than 7 years, the discharge of debtor is required for bankruptcy.
a.
Yes No
Have you ever been a defendant in any litigation or administrative proceeding, other than as a
witness?
b.
Yes No
Has any license issued to you or any partnership or corporation of which you were a member
or officer by any public authority been denied, suspended or revoked?
c.
Yes No
Has a surety company declined to be surety on any bond written on you in the two years prior
to this application date?
d.
Yes No
Have you ever filed bankruptcy or has bankruptcy been filed against you? If filed within 7
years from the date of this application, please provide a copy of the discharge. If over 7 years
ago, please provide a signed written statement. Please include bankruptcy type, state filed,
and date of discharge on an attached sheet.
e.
Yes No
Have you ever been convicted of a felony, gross misdemeanor, or misdemeanor?
f.
Yes No
Are you presently on parole or probation or paying any restitution?
g.
Yes No
Have you ever been convicted of, or are you under indictment for or have you entered a plea
of guilty or nolo contendere to forgery, embezzlement, obtaining money under false
pretenses, larceny, extortion, conspiracy to defraud or any crime involving moral turpitude?
4. PURSUANT TO NRS 645D.195, THE FOLLOWING STATEMENT MUST BE ANSWERED AND SIGNED. YOUR
APPLICATION FOR THE ISSUANCE OF THIS CERTIFICATE WILL BE DENIED IF YOU DO NOT INDICATE ON
THE STATEMENT WHICH OF THE PROVISIONS THAT APPLIES TO YOU.
I am NOT subject to a court order for the support of a child.
I am subject to a court order for the support of one or more children and AM IN COMPLIANCE with that order or plan
approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed in that
order.
I am subject to a court order for the support of one or more children and NOT IN COMPLIANCE with that order or plan
approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed in that
order.
I hereby certify under penalty of perjury that the answers contained in this application are true and correct.
I understand that if I am subject to a court order for support of one or more children and I am not in compliance with that order or
plan, my application for certification or renewal of a certification will be denied.
I further certify that I will faithfully comply with all the statutes and regulations of the State of Nevada pertaining to the conduct of
real estate licensees in the State of Nevada.
I, by signing this application, authorize any person or institution to which reference is made by me in connection with the application
to release or divulge to the Real Estate Division any information in the possession of such person or institution regarding me.
Applicant name (Print)
Signature
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
realest@red.nv.gov * http://red.nv.gov/
Revised 6/25/2019 Page 4 of 5 Form 639
CONSENT TO SERVICE OF PROCESS
FOR NON-RESIDENT USE ONLY
Name:
First MI Last
Hereinafter referred to as “Applicant,” hereby irrevocably constitutes and appoints the Administrator of the
Division of Real Estate, Department of Business & Industry, State of Nevada or his/her successor in office, to
be his/her true and lawful attorney within this state, upon whom all legal process in any suit, action or
proceeding arising under, or in any way connected with any provisions of Chapter 645, 645C, 119, 119A,
119B of Nevada Revised Statutes, or any rule or order pursuant thereto, or based upon any fraud, deceit,
breach or contract or other thing connected with the sale or offer for sale, negotiation or appraisal of any real
estate, timeshare or campground membership, may be served upon said applicant, personally within the State
of Nevada. Until the applicant attests by affidavit to the Administrator that he/she is a bona fide resident of
the State of Nevada, this appointment and the authority of said attorney shall continue in force and effect so
long as any such liability remains outstanding, and a copy of any process served hereunder may be sent by
certified mail, return receipt requested, addressed to:
Street Address
City
State
Zip Code
Drivers License Number
State
State of
ss. County of
This instrument was acknowledged before me in the possession of_______________________________________.
Print name of person presenting document
(Signature of person who presents the document)
Date
Signature of Notarial Officer
My Commission Expires:
(Seal)
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
realest@red.nv.gov * http://red.nv.gov/
Revised 6/25/2019 Page 5 of 5 Form 639
REPORT OF EXISTENCE OF NEVADA BUSINESS LICENSE
Pursuant to NRS 645C
All applicants MUST complete this section. Please select ONE option.
I have a Nevada business license number assigned by the Nevada Secretary of State upon compliance
with the provisions of NRS Chapter 76.
My Nevada business license number is: _______________________________________
I have applied for a Nevada business license with the Nevada Secretary of State upon compliance with
the provision of NRS Chapter 76 and my application is pending.
I do NOT have a Nevada business license number.
The Real Estate Division is not the arbiter of determining whether the applicant needs a business license.
Information about the Nevada business license can be found on the Secretary of State’s website at:
http://nvsos.gov/
ARE YOU A VETERAN?
Yes
No
0505RCCD-003(07/2017rev)
Fingerprint Background Waiver Page 1 of 2
Fingerprint Background Waiver
As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based
criminal history record check for a noncriminal justice purpose you have certain rights which are
discussed below.
1. You must be notified by the Nevada Real Estate Division (name of requesting agency)
that your fingerprints will be used to check the criminal history records of the FBI and the
State of Nevada.
2. If you have a criminal history record, the officials making a determination of your suitability
for the job, license or other benefit for which you are applying must provide you the
opportunity to complete or challenge the accuracy of the information in the record. You may
review and challenge the accuracy of any and all criminal history records which are returned
to the submitting agency. The proper forms and procedures will be furnished to you by the
Nevada Department of Public Safety, Records Bureau upon request. If you decide to challenge
the accuracy or completeness of you FBI criminal history record, Title 28 of the Code of
Federal Regulations Section 16.34 provides for the proper procedure to do so:
16.34 - Procedure to obtain change, correction or updating of identification
records. If, after reviewing his/her identification record, the subject thereof
believes that it is incorrect or incomplete in any respect and wishes changes,
corrections or updating of the alleged deficiency, he/she should make application
directly to the agency which contributed the questioned information. The subject of
a record may also direct his/her challenge as to the accuracy or completeness of any
entry on his/her record to the FBI, Criminal Justice Information Services (CJIS)
Division ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306.
The FBI will then forward the challenge to the agency which submitted the data
requesting that agency to verify or correct the challenged entry. Upon the receipt of
an official communication directly from the agency which contributed the original
information, the FBI CJIS Division will make any changes necessary in accordance
with the information supplied by that agency.
3. Based on 28 CFR § 50.12 (b), officials making such determinations should not deny the
license or employment based on information in the record until the applicant has been
afforded a reasonable time to correct or complete the record or has declined to do so.
4. You have the right to expect that officials receiving the results of the fingerprint-based
criminal history record check will use it only for authorized purposes and will not retain or
disseminate it in violation of federal or state statute, regulation or executive order, or rule,
procedure or standard established by the National Crime Prevention and Privacy Compact
Council.
0505RCCD-003(07/2017rev)
Fingerprint Background Waiver Page 2 of 2
5. I hereby authorize the Nevada Real Estate Division (name of requesting agency)
(name of requesting agency), to submit a set of my fingerprints to the Nevada Department
Public Safety, Records Bureau for the purpose of accessing and reviewing State of Nevada
and FBI criminal history records that may pertain to me.
In giving this authorization, I expressly understand that the records may include information
pertaining to notations of arrest, detainments, indictments, information or other charges for
which the final court disposition is pending or is unknown to the above referenced agency.
For records containing final court disposition information, I understand that the release may
include information pertaining to dismissals, acquittals, convictions, sentences, correctional
supervision information and information concerning the status of my parole or probation
when applicable.
6. I hereby release from liability and promise to hold harmless under any and all causes of legal
action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my
criminal history records search and provided information to the submitting agency for any
statement(s), omission(s), or infringement(s) upon my current legal rights. I further release
and promise to hold harmless and covenant not to sue any persons, firms, institutions or
agencies providing such information to the State of Nevada on the basis of their disclosures. I
have signed this release voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar
process, shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature
voluntarily appears below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEASE PRINT
Last Name
First Name
Middle
ADDRESS:
PLEASE PRINT
Applicant’s Signature:
Date:
Submitting Agency:
Nevada Real Estate Division
Address:
3300 West Sahara Avenue #350
Las Vegas, NV 89102
Agency Representative:
PLEASE PRINT
Last Name
First Name
Middle
Agency Representative Signature:
Date:
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CHECKLIST AND APPLICATION FOR REINSTATEMENT INSPECTOR OF STRUCTURES (Nevada Real Estate Division)

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Completed 28 December 2021

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