State Form 47478 - Application For Reassignment Of Real Estate License

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APPLICATION FORREASSIGNMENT

INDIANA REAL ESTATE COMMISSION

Reset Form

PROFESSIONAL LICENSING AGENCY

OF REAL ESTATE LICENSE

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

State Form 47478 (R4 / 12-08)

Telephone: (317)-234-3009

Approved by State Board of Accounts, 2009

INSTRUCTIONS:

For information on how to complete this application, including all applicable fees, please visit our website at .

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

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

FOR OFFICE USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

License obtained by

DO NOT WRITE ABOVE THIS LINE

Type of application (check one)

Transfer

Transfer to State

Transfer as referral status

Broker to hold own license

SECTION A - TRANSFERRING SALESPERSON OR ASSOCIATE BROKER

Name of licensee

License number

Social Security number

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

T elephone 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 CORPORATION / PARTNERSHIP / LLC

Name of corporation / partnership / LLC

License number of corporation / partnership / LLC

Name of releasing broker

License number of releasing broker

Social Security number of releasing broker *

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

T elephone number

(

)

Signature of releasing broker or principal broker of the corporation / partnership / LLC

Date (month, day, year)

SECTION C - TRANSFERRING INFORMATION

The requesting broker / corporation / partnership / LLC named below requests the license of the salesperson or associate broker to be assigned to its

license and has the full responsibility for the salesperson’s or associate broker’s actions in real estate transactions while associated with the requesting

broker / corporation / partnership / LLC.

Name of requesting corporation / partnership / LLC

License number of corporation / partnership / LLC

Name of principal broker for corporation / partnership / LLC

License number of principal broker

Social Security number of principal broker *

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

T elephone number

(

)

Signature of requesting principal broker

Date (month, day, year)