Affiliation Notice Form - Board Of Registration Of Real Estate Brokers And Salespersons Commonwealth Of Massachusetts

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COMMONWEALTH OF MASSACHUSETTS
Division of Professional Licensure
Board of Registration of Real Estate Brokers and Salespersons
1000 Washington Street, Suite 710
Boston, MA 02118-6100
Main Number (617) 727-2373
Fax Number (617) 727-0139
AFFILIATION NOTICE
A Broker of Record should utilize this form to notify the Real Estate Board of a broker’s or salesperson’s affiliation and/or a
realestateboard@state.ma.us
termination of an affiliation.
Please send the completed form to the Board by e-mail at
,
or by
mail to Real Estate Board, 1000 Washington Street, Suite 710, Boston, MA 02118-6100.
Name of Real Estate Business or Name of Broker:
_________________________________________________________
License No. of Real Estate Business or Broker:
_________________________________________________________
Agent’s Name
Agent’s License No.
Salesperson or Broker
Affiliation or
Effective Date
Termination
I, the Broker of Record, do state under the pains and penalties of perjury, that all statements contained in this form are true and
correct to the best of my knowledge and belief.
__________________________________________
___________________
___________________
Name of Broker of Record
License No.
Date
CHECKLSTandFORMS/ Affiliation Notice
Real Estate Main Number
Real Estate Fax Number
(617) 727-2373
(617) 727-0139

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