State Form 934 - Application For Real Estate License As Partnership Or D / B / A - State Of Indiana

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FOR OFFICE USE ONLY
APPLICATION FOR REAL ESTATE LICENSE AS PARTNERSHIP OR D / B / A
License number
Check digit
State Form 934 (R7 / 2-97)
Approved by State Board of Accounts, 1990
Date granted
County code number
Date license mailed
Control number
INSTRUCTIONS: 1. Mail fifty dollar ($50.00) License Fee to: Indiana Professional Licensing Agency
302 W. Washington St., Rm. E034
Indianapolis, IN 46204
SOLE OWNER - NO FEE
PARTNERSHIP - $50.00
Personal and Company checks
cause a 2 week processing delay.
COMPANY INFORMATION
Name of company
Check one
County
Partnership
Sole Owner DBA
Address (Number and street, or rural route, city, state, Zip code)
RESIDENTIAL ADDRESS
NAME(S) OF PARTNERS OR SOLE OWNER
CHECK ONE
LICENSE NUMBER
Partner
Sole Owner
Partner
Sole Owner
Partner
Sole Owner
RESIDENTIAL ADDRESS
LICENSE NUMBER
NAME OF PRINCIPAL BROKER
CHECK ONE
Partner
Sole Owner
NAME(S) OF SALESPERSONS AND BROKERS
CHECK ONLY ONE
RESIDENTIAL ADDRESS
LICENSE NUMBER
Salesperson
Broker
Salesperson
Broker
Salesperson
Broker
Salesperson
Broker
Salesperson
Broker
Signature of Partner or Sole Owner
Date
Telephone number
(
)

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