Change Of Employer Application Form (Page 3 of 4) in pdf

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

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: __ __ / __ __ / __ __ __ __

10. Original License Enclosed?  Yes

 No

EMPLOYER’S INFORMATION AS IT APPEARS ON THEIR LICENSE:

11. Employer’s Office Name:

12. Employer’s License Number:

APPLICANT BACKGROUND INFORMATION:

13. Do you hold, or have you ever held, a license, certificate, permit, registration or other authorization

to practice a profession or occupation in any state or jurisdiction?  No

 Yes

14. If you answered yes to the above question, please provide the profession_______________ and

state or jurisdiction _______________. Please do not abbreviate.

15. Since your initial application or last renewal, whichever is later, have you had disciplinary action

taken against a professional or occupational license, certificate, permit, registration or other

authorization to practice a profession or occupation issued to you in any state or jurisdiction or have

you agreed to voluntary surrender in lieu of discipline?  No

 Yes

16. Do you currently have any disciplinary charges pending against your professional or occupational

license, certificate, permit or registration in any state or jurisdiction?  No

 Yes

Change Of Employer Application Form Page 3

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