Office Registration Form - Department Of Commerce And Economic Development Division Of Occupational Licensing
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DEPARTMENT OF COMMERCE AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
FOR OFFICE USE ONLY
REAL ESTATE COMMISSION
3601 C STREET, SUITE 722
ANCHORAGE, ALASKA 99503-5986
i i
Phone: (907) 269-8162
E-mail: License@commerce.state.ak.us
OFFICE REGISTRATION
Fee:
$25.00 for office and first five licensees, and $5.00 for each additional licensee.
Attach List of Names and License Numbers
Opening New Office
Type of Organization
Business Activity (ies)
“ Main Office
“ Sole Proprietorship
“ Sales
“ Branch Office
“ LLC (Attach LLC Affidavit)
“ Property Management
“ Referral Office
“ Partnership (Attach Partnership Affidavit)
“ Commercial Sales & Leasing
“ Corporation (Attach Corporation Affidavit)
“ Community Association Management
Number of Licensees:
MAIN OFFICE
Business Name:
Telephone Number:
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:
Physical Location:
City:
Fax Number:
Mailing Address:
City:
State:
Zip Code:
Trust Account Name:
Number:
Bank Name:
Branch:
Associate Broker in Charge:
License Number:
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
this day of
, 19
.
Notary Public for the State of Alaska
My Commission Expires:
Return form to:
Division of Occupational Licensing, Real Estate Commission
3601 C Street, Suite 722, Anchorage, AK 99503-5986
08-4005 (Rev. 6/98)
GO/dgl
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