CHANGE FORM - REAL ESTATE
Access this form via website at:
REAL ESTATE COMMISSION
Form is 2 pages. Signature(s) REQUIRED on page 2!
DCCA, PVL Licensing Branch
Submit ORIGINALS only - FAX and PHOTOCOPIES will not be accepted.
P.O. Box 3469
Use fillable feature or print in BLUE or BLACK INK ONLY). READ instructions carefully.
Honolulu, HI 96801
Legal Name of Individual or Business Entity:
335 Merchant St., Room 301
Honolulu, HI 96813
License Name (Individual's First, Middle, LAST, or Entity)
Residence Location Address, if individual or sole proprietor: (NO P.O. BOX)
Business Address only if entity: (NO P.O. BOX)
Phone Number (days)
INDICATE CHANGE BEING REPORTED BELOW: NO changes will be recorded unless:
-- appropriate box(es) is/are checked
-- required signatures are on page 2
-- checks are made payable to "Commerce and Consumer Affairs"
(Note: a $25 service charge will be assessed for payments that are dishonored for any reason, and the requested
change will not be processed. If no fee is indicated, there is no fee for that change.)
The effective date of a change will be as indicated on the form. You must submit changes within 10 days of the change as required by Rule
16-99-5. Failure to comply may result in disciplinary action.
Change RESIDENCE LOCATION ADDRESS to address above.
Delete (check one) TRADE NAME
Sign and date page 2 in Section B.
(entity only, includes sole proprietor). Submit a copy of the
"Application for Registration of Trade Name" that has been
Change MAILING ADDRESS. Complete "Mailing Address"
filed-stamped by the Business Registration Division, Commerce
above. Sign and date page 2 in Section B.
and Consumer Affairs. Sign and date page 2 in Section B.
Change BUSINESS ADDRESS of principal place of business or
branch office. Sign and date page 2 in Section B to certify that
the new business address is in compliance with Chapter 467,
HRS, and Chapter 99, HAR. Fee: $10
New business address:
Change legal NAME OF ENTITY or INDIVIDUAL. Attach old
wall certificate and copy of legal document showing name
change (Entity: File-stamped copy of "Certificate of
Amendment" filed with the Business Registration Division,
Commerce & Consumer Affairs and an entity resolution.
Individual: Marriage certificate, divorce decree, etc.). Sign and
date page 2 in Section B. Fee: $10
Delete (check one) LICENSE NAME of
Request DUPLICATE LICENSE. Indicate type below. Fee: $10 for
individual. Sign and date page 2 in Section B. The license
each license or certificate. Sign and date page 2 in Section B.
name of individual broker, RBS, or salesperson shall include the
individual's full legal surname. Fee: $10
SURRENDER of License (individual, entity, or branch office): Complete Section A above. A licensee who has no pending complaints, investigations,
disciplinary petitions filed against the licensee or disciplinary hearings may surrender the license. Attach wall certificate and pocket license. If the
pocket ID card and/or wall certificate are not available, please provide a written explanation as to why they cannot be provided. Once license is
surrendered, the person who desires to engage in real estate activity in the future must meet all requirements as a new applicant. Sign and date page
2 in Section B.
Place license INACTIVE. Complete Section A above. Releasing principal broker or broker in charge must complete Section C on page 2 and the
signature of licensee who is going inactive is required in Section B. If unable to obtain signature of licensee who is going inactive, Rule 16-99-5.1(c)
requires the releasing broker to provide the licensee written notification. NOTE: If the licensee is unable to obtain releasing broker's signature, please
review the memorandum "Procedures for Difficulties with Releasing Broker on the Change Form or Experience Statement by Broker" on the Real Estate
Branch website. If BIC is being placed on inactive status, PB must sign Section C. (BIC NOT AUTHORIZED TO SIGN THEMSELVES OR OTHER BIC'S
ON OR OFF.)
Licensee Deceased. Provide a copy of death certificate or obituary. Signature of individual submitting the information is not required.
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