Office Changes Form - Department Of Commerce, Community And Economic Development
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OFFICE CHANGES
Fee: $50.00 for each licensee
FOR OFFICE USE ONLY
(Applies to changes which would require a new license only; i.e. change broker or
change of business name).
Enclose original license certificates (signed and dated by employing
broker) of all licensees in office, including broker
Change Broker
Close office (no fee)
Change Business Name
Change of Associate Broker in Charge
Main Office
Referral Office
Branch Office
MAIN OFFICE
Business Name:
Telephone Number:
Owner of Business: _______________________________________________________________________________ ________________
(Print the name of Sole Owner, Corporation, LLC or LLP as applicable)
(If applicable) Corporation Entity #: __________________ Partnership #: _____________________ or LLC Entity # _________ ___________
Physical Location:
City:
Fax Number:
Mailing Address:
City:
State:
Zip Code:
Trust Account Name:
Number:
Bank Name:
Branch:
Broker of Record:
License Number:
(Please PRINT)
BRANCH OFFICE
Business Name:
Telephone Number:
Owner of Business: _________________________________________________________________________________ ______________
(Print the name of Sole Owner, Corporation, LLC or LLP as applicable)
(If applicable) Corporation Entity #: __________________ Partnership #: _____________________ or LLC Entity # ______________ ______
Physical Location:
City:
Fax Number:
Mailing Address:
City:
State:
Zip Code:
Trust Account Name:
Number:
Bank Name:
Branch:
Associate Broker in Charge:
License Number:
(Please PRINT)
Associate Broker Signature:
Date:
AFFIDAVIT OF BROKER STATEMENT
I HEREBY CERTIFY that the above information is true and correct to the best of my knowledge. I understand that any false or misleading
information may result in suspension or revocation of my license.
Date:
Broker of Record:
(Broker Signature)
SUBSCRIBED AND SWORN TO before me this
day of
,
.
SEAL
Notary Public for the State of ___________
My Commission Expires:
08-4005 (Rev. 08/2010)
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