Change Of Employer Application Form printable pdf download

4/2015

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 – ASSOCIATE BROKER -

CEMETERY ASSOCIATE BROKER

Make sure this is the most recent application by checking our website. Failure to submit a current

application could result in delays while processing your application.

PLEASE READ THE FOLLOWING BEFORE PROCEEDING WITH THE APPLICATION PROCESS

Licensees who wish to use and advertise a nickname for their first name shall include the nickname on

their licensure applications or biennial renewal applications. If you are using a nickname that was not

previously reported, please provide this information now.

If a pending application is older than one year from the date submitted and the applicant wishes to

continue the application process, the Commission shall require the applicant to submit a new application

including the required fee.

In order to complete the application process, many of the supporting documents associated with the

application cannot be more than six months from the date of issuance. All background check documents

cannot be older than 90 days from the date of issuance.

Failing to answer any questions or providing false answers may result in the refusal of a license or

subsequent disciplinary action once the license is issued.

Change of employment applications must be submitted within 10 days of the change.

If your

license is currently active, upon submission of a completed application, you may begin practicing

UNLESS the broker has not been issued a Pennsylvania license. A copy of this application must be

kept on file with the broker/builder-owner until the new license has been issued. All original wall

certificates must be returned.

If you changed your name for any reason, copies of legal documents supporting this change must be

submitted. Legal documents include marriage certificates, divorce decrees that state you are retaking

a maiden name, or other court documents verifying the name change. Driver’s licenses and social

security cards are not acceptable to verify a name change.

SOCIAL SECURITY NUMBER DISCLOSURE: NOTICE: Disclosing your Social Security Number on this

application is mandatory in order for the State Boards to comply with the requirements of the Federal

Social Security Act pertaining to Child Support Enforcement, as implemented in the Commonwealth of

Pennsylvania at 23 Pa.C.S. § 4304.1(a). At the request of the Department of Human Services (DHS), the

licensing boards must provide to DHS information prescribed by DHS about the licensee, including the

social security number.

Licenses are not forwarded. Provide your current address to receive correspondence from the

Commission. It is the applicant’s responsibility to inform the Commission of an address or name change

within ten (10) days of the change. Refer to the “Name/Address Change” form located on our website.

Change Of Employer Application Form