Request To Reissue Real Estate License Certificate And/or Renewal/reinstatement Card (Form Rec 1.22) - North Carolina Real Estate Commission
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1FOR COMMISSION USE ONLY
North Carolina Real Estate Commission
PC____________LC____________
P.O. Box 17100, Raleigh, N.C. 27619-7100
Date_________________________
Phone (919) 875-3700 • Email: info@ncrec.gov
I.S.__________________________
Fax (919) 877-4221 • Website:
Order ID_____________________
REQUEST TO REISSUE REAL ESTATE LICENSE CERTIFICATE
AND/OR RENEWAL/REINSTATEMENT CARD
Instructions
The Real Estate Commission can issue a real estate license certificate and/or renewal/reinstatement card only
if the original license or card has been lost, damaged, or was never received, or if the name of the licensee has
been legally changed (either by reason of marriage or otherwise). To have a real estate license and/or renewal/
reinstatement card reissued, please provide the following information. Forms not properly completed
cannot be processed. (All fees are nonrefundable.)
I hereby certify to the North Carolina Real Estate Commission that [check appropriate option(s)]:
My real estate license renewal/reinstatement card was never received (if more than 45 days since
license issuance or renewal/reinstatement), has been lost or damaged, and I request a replacement ($5
fee required).
My real estate license certificate was never received (if more than 45 days since license issuance), has
been lost or damaged, and I request a replacement ($5 fee required).
My real estate license renewal/reinstatement card was never received, and I request a replacement
(Only select this option if your request is within 45 days of license issuance or license renewal/
reinstatement).
My real estate license certificate was never received, and I request a replacement (Only select this
option if your request is within 45 days of license issuance).
My name was legally changed on (date) ________
($10 fee required)
from:______________________ ________________________ ________________________
(First)
(Middle)
(Last)
to:________________________ ________________________ ________________________
(First)
(Middle)
(Last)
By reason of:
and I, therefore, request that my real
estate license and renewal/reinstatement pocket card be reissued accordingly.
Note: If your name has been changed for reasons other than marital status include a copy of
the legal document showing the name change.
Your license will be issued in your First Name, Middle Name and Last Name.
Type of License:
Broker
Firm
Firm Name:_________________________________________ Firm License Number:_______________
(Please Print)
Licensee Name:______________________________________ License Number:___________________
(Please Print)
Physical Address:______________________________________________________________________
(Address)
(City)
(State)
(Zip+4)
Mailing Address:________________________________________________________________
(Address)
(City)
(State)
(Zip+4)
Please check here if this is a new residence address
Public Phone:______________________________ Private Phone:_______________________________
Public Email: ______________________________ Private Email:_______________________________
Signature:_____________________________________________________ Date:__________________
REC 1.22
REV 5/2016
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