Realtor Change Form

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REALTOR
®
Change Form
BROKER_OR_OFFICE_MANAGER_MUST_SIGN_UNDER_SIGNATURE_AREA_IF_TERMINATING_OR_TRANSFERRING_AN_AGENT
Date__________________________________
First_Name_____________________________ Last_Name_ ______________________Middle_Name_________________
MLS_Number/NRDS________________________________________________________________________________
CHECK APPROPRIATE BOX(ES)
o_TRANSFER (complete this section if an agent is transferring from one office to another)
Transferring_FROM_(old_office)_Name:________________________________________________________________
Address____________________________ _City________ State__________________ _Zip______________________
Transferring_TO_(new_office)_Name:_ _ ________________________________________________________________
Address____________________________ _City________ _State_ ________________ _Zip______________________
Preferred_Email_________________________________________________________________________________
o_Change Personal Information (complete this section if your personal information is changing in any way)_
Name_ _____________________________________________ Email______________________________________
Street_Address__________________________________________________________________________________
City_____________________________________ _State________Zip_____________ County____________________
Preferred_Phone____________________________ Mobile_Phone_ _________________________________________
o_Change Office Information (complete this section if the office is changing it’s name, phone #, email address.
Agents transferring use the office transfers section.)
_
Old_Office_Name___________________________________________ MAAR_Office_ID_#______________________
New_Office_Name_______________________________________________________________________________
New_Address___________________________________________________________________________________
City_______________________________ _State_ ______ _Zip_ ______________ _County______________________
Office_Phone____________________________________ _Fax_____________________________________________
Website_______________________________________ _Email__ _ __________________________________________
Brokers – Check the appropriate box below to terminate an agent. License must be terminated on the Pulse Portal
website. If this agent holds an eKEY, please have the agent contact our Supra department to arrange termination.
Supra will continue to bill DisplayKEY holders until their DisplayKEY and cradle are returned to the association.
Reason for Termination_–_please_check_the_appropriate_box(es):
o_Transferred_to_another_office/association_
o_Did_not_pay_dues_
o_Retired
o_Transferred_to_a_non-REALTOR
o_Unsure,_cannot_reach_
o_Deceased
_office_
®
o_Transferred_to_an_LFRO_entity_
o_Military_leave
o_Left_real_estate_industry*_
o_Putting_license_on_hold
*_
NOTE_THAT_IF_AGENT_BECOMES_INACTIVE_FOR_MORE_THAN_60_DAYS,_THERE_IS_$100_REINSTATEMENT_FEE.
Print_Name_Clearly_ ________________________________________________________________________________
_ Signature_of_Agent/Office_Staff_(Needed_if_changing_personal_contact_info)_________________________________________
_
Signature_of_Broker/Office_Staff_(Needed_if_transferring_or_terminating_an_agent)____________________________________
_
BROKER_OR_OFFICE_MANAGER_MUST_SIGN_UNDER_SIGNATURE_AREA_IF_TERMINATING_OR_TRANSFERRING_AN_AGENT_
Revised_August_18
5750 Lincoln Drive • Minneapolis, MN 55436 • 952.933.9020 phone • 952.933.9021 fax •

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