Certified License History Order Form
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3229 Peachtree Street NE
Suite 1000 - International Tower
Georgia Real Estate Commission
Atlanta, GA 30303-1605
Georgia Real Estate Appraisers Board
Phone: 404-656-3916
Fax: 404-656-6650
Email: grecmail@grec.state.ga.us
Real Estate Change Application
This form can be filled out on-line. Print TWO copies: one to sign and submit for processing and one for your records. If a fee and/or
additional documentation is required, attach to the application and mail to the address above. Once the completed application,
including all supporting documents, is received the application will be processed. Incomplete applications will be returned
unprocessed and result in a $25.00 charge.
Salespersons / CAMS Complete sections A, B, C, E, and Sign in Section F of this application.
Brokers Complete sections A, B, D, E, and Sign in Section F of this application.
Individual Information
Section A
Full Name:
License Number:
Phone Number:
Section B
Change Information
Address / Phone numbers can also be changed instantly by logging in at
E-mail
Residence
Address
State
Zip Code
City
County
Phone Number
Mailing
Address
State
Zip Code
City
County
Phone Number
Fax Number
Change my Name
Print New Name:
Be sure to sign Section F of this application with this name.
Send a replacement wall certificate and pocket card
Licensee is deceased
Attach a copy of the obituary or death certificate.
FOR OFFICE USE ONLY
Proc By & Proc Dt
Rec By
Lic#
Fee
Codes
INV
Rec Dt
Educ
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GREC Change App
(12-2016)
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