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.I <br /> ~ O ~ O~ APPRAISER CERTIFICATION <br /> ~ AND LICENSURE BOARD <br /> 3000 MARKET STREET NE, SUITE 541 <br /> Q ~ v ~ ' ~ <br /> ' SALEM OR 97301 <br /> H , _ <br /> PHONE (503) 485-2555 <br /> * z FAX (503) 485-2559 <br /> ~ TDD/I-~ARING IMPAIRED (503) 378-4100 <br /> www.oregonaclb.org <br /> J 8 5 9; <br /> ~ 1'1Z,~~ISI;12, ~ 1~ _ IC`-i.~l~lON l~p ~ <br /> INSTRUCTIONS: Please. type or print legibly in ink the following information required to renew your license or certificate. To <br /> <br /> r avoid a $50 Late fee, your application must be signed, dated, accompanied by the appropriate fee, Official Transcripts or copies of <br /> signed Certificates of Completion for continuin education, a current 2x2 color ass ort-s le hoto and received in the ACLB office <br /> g p p tY P <br /> no later than the ex ~ at' <br /> ptr ton date of your current license or certificate to mamtam an active status (postmark date is not acceptable). <br /> ~'`,I~Z Ora t I Z _~~©r /`~o©~ °7/3 ! /2~8 <br /> License/Certificate Numb/er Issue D~ Expira on Da e <br /> APPLICANT: ~W ~ ~ L ~Y!?I S ~ CA~f <br /> Last Name First I~Tame M.I. r~ ~ <br /> HOME ADDRESS: ~ d CJ ~dr /U ~V~d",U~ , ~ ~ 1GOt~ <br /> Address Ci State Zip Code <br /> MAILING ADDRESS (If different):_~~~J <br /> Address City State Zip Code <br /> coU1vTY: ~ ~ ~ t 3 c c~ c1 Z- ~ ~ <br /> a -~3 ~ <br /> (Home Phone) (Work Phone) (Fax Number) <br /> SOCIAL SECURITY NUMBER: ~~C d~ ~ - 'f ~~o SEX: MALE FEMALE <br /> (Required/Mandatory) <br /> DATE AND PLACE OF BIRTH: ~ ~ ~ ~U~~/Ufc Q~~G ~ ~ <br /> l Month Day Year City State <br /> DRIVER LICENSE NUMBER: ~ Z <br /> ~ , STATE OF ISSUE:_ ®~(c~ ~J N <br /> ,US CITIZEN OR LEGAL RESIDENT: Yes No E-MAIL ADDRESS: 1) , C .\K~tGl,9~vrr.S ~ GT. Fc(.AG-.~//`y,E <br /> ~~r~s,r v S . <br /> NAME OF EMPLOYER OR DBA (This name will be reflected on your lic~eynse or certificate): ~ ~~_[rZ~ C~-y/~, <br /> BUSINESS OR EMPLOYER NAME/ADDRESS (ioema~og cry, st. zip>: ~5 .~~GY~ ~-C ~ ] <br /> : t~(Jfr.,E~?/.~~ ~C l <br /> T/ J <br /> THE RENEWAL FEE FOR LICENSING AND CERTIFICATION IS: <br /> $550 f or two (2) years <br /> (This includes your $25 annual federal registry fee ($50) for two (2) years) <br /> INACTIVE LICENSE OR CERTIFICATE: $100 ? .FOR LATE RENEWAL FEE: $50 <br /> DO NOT SEND CASH. MAKE CHECK OR MONEY ORDER PAYABLE TO "ACLB" <br /> Revised 01/08 <br /> renapp.pdf <br /> <br />