Personal Name Change/home Address Change/duplicate License printable pdf download

Personal Name Change/home Address Change/duplicate License

Bureau of Professional and Occupational Affairs

Real Estate Commission

PO Box 2649, Harrisburg, PA 17105-2649

717-783-3658; 717-787-0250 (FAX)

PERSONAL NAME CHANGE/HOME ADDRESS CHANGE/DUPLICATE LICENSE

This request form is used to process a change of personal name and/or address on an individual’s license record or to

request a duplicate copy of an existing, active license.

CHECK THE APPROPRIATE BLOCK AND COMPLETE THE REQUESTED INFORMATION

CHANGE OF PERSONAL NAME

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With this form provide clear copies of documents supporting the name change. You must submit one of the

following: (1) marriage certificate or (2) divorce decree which indicates the retaking of your maiden name or

(3) the court document approving the legal name change.

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Because it is required that the license in your employing broker’s office reflect your correct name, you must also

choose the Duplicate License option below and provide the accompanying fee.

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Complete the information below.

CHANGE OF HOME ADDRESS AND/OR EMAIL ADDRESS

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Complete the information below. No fee is required as this information is not printed on your license.

DUPLICATE LICENSE

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Complete the information below.

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A $5.00 fee in the form of a check or money order made payable to Commonwealth of PA, must be submitted

with this form for the duplicate license. A processing fee of $20.00 will be charged for any check returned

unpaid by your bank, regardless of the reason for non-payment.

Name currently on license:___________________________________________________________________________

Name changing to (if applicable):______________________________________________________________________

Date of Birth:_____________________ SSN:___________________ License Number:__________________________

Previous Address/Email Address:______________________________________________________________________

_________________________________________________________________________________________________

New Address/Email Address (if applicable):______________________________________________________________

__________________________________________________________________________________________

Personal Name Change/home Address Change/duplicate License