Change Of Employer Application - Standard Or Reciprocal Licensees (Page 3 of 4) in pdf

Change Of Employer Application - Standard Or Reciprocal Licensees Page 3

56-SPOA 2102 (6/13)

STATE REAL ESTATE COMMISSION

Phone Number 717-783-3658

PO Box 2649

Fax Number: 717-787-0250

Harrisburg PA 17105-2649

CHANGE OF EMPLOYER APPLICATION – STANDARD OR RECIPROCAL LICENSEES

REAL ESTATE SALESPERSONS – CAMPGROUND MEMBERSHIP – TIMESHARE SALESPERSONS

BUILDER-OWNER SALESPERSON – CEMETERY SALESPERSON

1. Applicant’s Legal Name:

2. Applicant’s License Number:_

3. Applicant’s Nickname (if applicable):

4. Applicant’s Home Address:

(Street)

(City)

(State)

(Zip)

5. Applicant’s Social Security Number: __ __ __ - __ __ - __ __ __ __

6. Applicant’s Date of Birth: __ __ / __ __ / __ __ __ __

7. Applicant’s Phone Number: (__ __ __) __ __ __ - __ __ __ __

8. Applicant’s Email Address:

Check here if you would like to receive communications regarding your

application via email. If you check this box, please be sure to add

ra-realestate@pa.gov

to your address book.

9. Effective Date of Employment with the new broker: __ __ / __ __ / __ __ __ __

BROKER INFORMATION AS IT APPEARS ON THEIR LICENSE:

10. Employing Broker’s Office Name:

11. Employing Broker’s Office Address:

(Street)

(City)

(State)

(Zip)

12. Employing Broker’s Office Phone Number: (__ __ __) __ __ __ - __ __ __ __

13. Employing Broker’s License Number:

APPLICANT:

14. Have you ever been issued a real estate license in another state?

Yes – Type of License:

State:

License Number:

15. Have you ever been issued any other professional license in any state, Pennsylvania included?

Yes – Type of License:

License Number:

16. Have you ever had a real estate license or other professional license disciplined?

Yes – Where:

When:

If yes, include the information requested in section 8 in the instructions.

Change Of Employer Application - Standard Or Reciprocal Licensees Page 3

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