Any real estate broker who is convicted of a misdemeanor or felony criminal offense or who has had any disciplinary action
taken against him or her in connection with any other professional license (real estate or other) must notify the North
Carolina Real Estate Commission in writing within 60 days following the final judgment or final order in the case. [Commission
Rule A .0113
, eff. August 1, 1996, amended effective July 1, 2000.]
To report a criminal conviction or disciplinary action, complete this form and return to the N.C. Real Estate Commission,
Attn: Regulatory Affairs Division.
Include with this form a certified copy of the judgment of the court or order of the licensing agency and a detailed
statement in your own words describing all relevant facts and circumstances surrounding the conviction/disciplinary
action. If you are reporting an N.C. conviction for impaired driving you should also include a copy of the Impaired
Driving Determination of Sentencing factors (Form AOC-CR-311).
For further information concerning reporting criminal convictions or disciplinary actions, contact the Real Estate Commission’s
Regulatory Affairs Division, (919) 719-9180.
This form is not meant to be printed. If you have already completed the form please use the submit button at the bottom
to send the form directly to the Commission.