North Carolina Real Estate Commission - Broker-In-Charge Declaration
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1
2NORTH CAROLINA REAL ESTATE COMMISSION
FOR COMMISSION USE ONLY
PO Box 17100, Raleigh, NC 27619-7100
Phone (919) 875-3700 •Fax (919) 877-4221
REPL
LIC #
W eb Address:
NLBIC@
E-mail: informationservices@ncrec.gov
FIRMS
BROKER-IN-CHARGE
DECLARATION
Instructions
1.
Qualifications and responsibilities of a broker-in-charge are detailed on the back of this form. Please review these
carefully.
2.
If the firm has more than one office where real estate brokerage activities are conducted, duplicate and submit a separate
form for each office. A broker practicing alone shall designate himself or herself as broker-in-charge.
3.
For initial designation, brokers must complete the Commission’s Broker-in-Charge Course within three years prior to
or 120 days following designation as broker-in-charge.
4.
SPECIAL NOTE: If you are completing this form because you are seeking to restore a broker-in-charge designation or
eligibility, Commission Rule A.0110 requires that in order to re-designate yourself you must: 1) first be on active status;
2) have the experience required for initial designation; and, 3) then complete the 12-hour Broker-in-Charge Course and
then re-designate.
5.
If you do not receive a Notice of License Record Change within 10 business days after filing this form, you should contact
the Commission’s Information Services Section.
* * * *
BROKER-IN-CHARGE:
(Print or Type Name)
(NC Real Estate License No.)
FIRM BUSINESS NAME:
FIRM LICENSE NUMBER:
(Not required if sole proprietorship or when applying for a new
firm license)
TYPE OF FIRM: [Check one]
Corporation
LLC
Partnership
Sole Proprietorship
PHYSICAL ADDRESS:
(Street)
(City)
(State)
(Zip + 4)
(County)
PO BOX (IF ANY):
(PO Box No.)
(City)
(State)
(Zip +4)
(County)
PHONE: (
)
FAX: (
)
E-MAIL:
IS THIS A NEW REAL ESTATE OFFICE?
YES
NO
IF NOT, PROVIDE THE NAME OF THE BROKER-IN-CHARGE YOU ARE REPLACING:
(NC Real Estate Licence No.)
(Print or Type Name)
Note: Any agent listed on the Commission’s records as affiliated with the previous broker-in-charge will be changed to
reflect you as their broker-in-charge of record unless you notify us in writing differently.
Certification
I certify to the North Carolina Real Estate Commission that I have been duly designated by the Qualifying Broker of the
real estate firm shown herein to serve as broker-in-charge for such firm at the office listed and that I have the experience
required for such designation. I further certify that I shall carry out my responsibilities as broker-in-charge for such office
in accordance with the Commission’s rules, that I shall directly supervise any and all licensed real estate provisional
brokers working from such office, and that I will continually maintain my license on active status.
BROKER-IN-CHARGE:
(Signature)
(Date Signed) *
* PLEASE NOTE THAT THIS FORM MUST BE FILED WITH THE COMMISSION WITHIN 30 DAYS OF THE DATE SIGNED TO BE VALID
REC 2.04
Page 1 of 2
REV 5/13
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