State Form 47478 - Application For Reassignment Of Real Estate License

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APPLICATION FOR REASSIGNMENT

INDIANA REAL ESTATE COMMISSION

OF REAL ESTATE LICENSE

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

State Form 47478 (R6 / 12-10)

Indianapolis, Indiana 46204

Approved by State Board of Accounts, 2011

Telephone: (317)-234-3009

E-mail: pla9@pla.in.gov

Your Social Security number is being requested by this state agency in accordance with Indiana Code. Disclosure is mandatory and this record cannot be processed without it.

Social Security numbers are available to the Indiana Department of Revenue.

INSTRUCTIONS:

1. Please type or print legibly.

2. Include a fee of $10.00 unless selecting Inactive or Unassigned.

3. Please have the releasing broker complete Section B.

4. If signatures are unavailable, please attach a letter of explanation.

FOR OFFICE USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Type of application (check one)

Transfer (CE required)

Inactive (No CE required)

Unassigned (CE required)

Referral (No CE required)

Broker to hold own license (CE required)

Activation (CE required)

SECTION A - TRANSFERRING SALESPERSON OR ASSOCIATE BROKER

Name of licensee (last, first, middle)

License number

Social Security number

Address (number and street, city, state, and ZIP code)

E-mail address (required)

Telephone number

(

)

I hereby swear or affirm that I have notified the releasing broker or corporation / partnership / LLC of my intentions to associate with another broker or

corporation / partnership / LLC.

Signature of licensee

Date (month, day, year)

SECTION B - TERMINATION OF ASSIGNMENT BY BROKER OR BROKER COMPANY

Name of Broker Company

License number of Broker Company

Name of releasing broker

License number of releasing broker

Social Security number of releasing broker *

Address (number and street, city, state, and ZIP code)

Telephone number

(