STATE OF CALIFORNIA DEPARTMENT OF REAL ESTATE Real Estate MATTERS! BROKER CHANGE APPLICATION (For Broker Licensees) RE 204 (Rev. /12) ¾ ¾ ¾ Received Date This form is to be used by brokers only (including those working as broker-salespersons). Licensed salespersons must use 5(  FRUSRUDWLRQV DQG FRUSRUDWLRQ RI¿FHUV PXVW XVH 5( 204A. Read instructions on reverse side before completing. Note: License changes with an asterisk may be completed online by using eLicensing. (Refer to information on page 2.) TYPE OF CHANGE (Mark one or more boxes) … Mailing Address* … 0DLQ 2I¿FH $GGUHVV … Personal Name … Add/Cancel Fictitious Business Name BROKER INFORMATION 1. LICENSE IDENTIFICATION NUMBER DRE USE ONLY 2. BROKER NAME (LAST) (FIRST) (MIDDLE) 3. BROKER NEW PERSONAL NAME (LAST) (FIRST) (MIDDLE) DRE USE ONLY 4. DO YOU RESIDE IN CALIFORNIA?.............................................................................................................................................................................. IF NO, AN “RE 234” MAY BE REQUIRED. SEE REVERSE SIDE. … YES … NO 5. BROKER MAILING ADDRESS (STREET ADDRESS OR POST OFFICE BOX) CITY STATE ZIP CODE DRE USE ONLY 6. BROKER MAIN OFFICE ADDRESS (STREET ADDRESS) — ENTER MAIN ADDRESS OR “NO BUSINESS ADDRESS"; DO NOT LEAVE BLANK. CITY STATE CA ZIP CODE DRE USE ONLY 7. RESIDENCE PHONE NUMBER 8. BUSINESS PHONE NUMBER ( ( ) 9. CELL PHONE NUMBER ( ) 10. EMAIL ADDRESS ) 11A. FICTITIOUS BUSINESS NAME (DBA) — PRINT AS IT APPEARS ON FILING FROM COUNTY CLERK. … ADD OR … CANCEL ‡ 5HIHU WR SDJHV   ‡ (QWHU RQH QDPH SHU OLQH ‡ &KHFN ³DGG´ RU ³FDQFHO´ ER[ ‡ $WWDFK )%16 ‡ %URNHU6DOHVSHUVRQ¶V ² 'R QRW OLVW \RXU HPSOR\HU RU \RXU HPSOR\HU¶V '%$ 11B. ADDITIONAL FICTITIOUS BUSINESS NAME, IF ANY … ADD OR … CANCEL 12. ORIGINAL SIGNATURE OF BROKER (IF NAME CHANGE HAS OCCURRED, USE NEW LEGAL NAME.) DATE DRE USE ONLY PROC. # COMMENTS DATE PROCESSED American LegalNet, Inc. www.FormsWorkFlow.com RE 204 INSTRUCTIONS Page 2 of 2 Try eLicensing Instructions ¾ Check the appropriate “change” box(es) on page 1 and complete all information requested on the application. Change of Personal Name — Enter full new name (do not refer to any RWKHU EURNHU '%$ RU FRPSDQ\ QDPH $WWDFK YHUL¿FDWLRQ RI QDPH FKDQJH LH OHJLEOH FRS\ RI GULYHUV OLFHQVH PDUULDJH FHUWL¿FDWH FRXUW RUGHU HWF Sign line #12 with your new name. If you have a DBA on record, a Fictitious %XVLQHVV 1DPH 6WDWHPHQW PXVW EH UH¿OHG ZLWK \RXU QHZ QDPH Mailing Address ² 7KH PDLOLQJ DGGUHVV SRVW RI¿FH ER[ UHVLGHQFH RU business address) is used to mail correspondence to you. Non-California Residents — If residing outside the State of California, a notarized Consent To Service Of Process (RE 234) is also required, if not DOUHDG\ RQ ¿OH ,I QRW PDLQWDLQLQJ DQ RI¿FH LQ &DOLIRUQLD VXEPLW DQ 2XW of-State Broker Acknowledgment (RE 235). 0DLQ 2I¿FH $GGUHVV — Enter the new primary business location. The main RI¿FH DGGUHVV must be a California address. If a street address is unavailable, indicate the physical location (i.e., the nearest intersection and the distance to it). If you are no longer working in real estate for which a California license is required, enter “no business address” on line #6. No license will be issued unless requested. Fictitious Business Name — Do not list your broker’s DBA, if you are working as a broker-salesperson. To add a DBA to your broker license, enter the name exactly as it appears RQ WKH )LFWLWLRXV %XVLQHVV 1DPH 6WDWHPHQW )%16 DV ¿OHG ZLWK WKH &RXQW\ &OHUN 7KH '%$ PXVW EH ¿OHG LQ WKH FRXQW\ RI \RXU PDLQ RI¿FH DGGUHVV 6XEPLW D FRS\ RI WKH )%16 ZLWK WKH ³¿OHG VWDPS´ IURP WKH &RXQW\ &OHUN¶V RI¿FH ‡ 3ULRU WR ¿OLQJ \RXU ¿FWLWLRXV EXVLQHVV QDPH VWDWHPHQW ZLWK WKH FRXQW\ \RX PD\ ZLVK WR FRQWDFW D ORFDO '5( GLVWULFW RI¿FH RU FKHFN RXU :HE site (www.dre.ca.gov) to determine if the name is already in use by another broker. ‡ 7KH EURNHU OLFHQVHH¶V QDPH PXVW DSSHDU DV D UHJLVWUDQW RQ WKH FBNS. Refer to Section 2731 of the Commissioner’s Regulations for restrictions. ‡ 3URRI RI 3XEOLFDWLRQ LV QRW DFFHSWDEOH XQOHVV LW EHDUV WKH &RXQW\ &OHUN¶V ³¿OHG VWDPS´ ‡ 3KRWRFRSLHV DUH DFFHSWDEOH LI WKH\ DUH FOHDU DQG OHJLEOH To cancel a DBA, complete the entire application. Check the cancel box on line #11A and list the DBA you wish to cancel. Use eLicensing for expedited processing of your change. Licensees can perform the following transactions using the eLicensing system at www.dre.ca.gov: ‡ %URNHU DQG VDOHVSHUVRQ UHQHZDOV ‡ /LFHQVH FHUWL¿FDWH UHTXHVWV EURNHU VDOHVSHUVRQ RI¿FHU DQG branch) ‡ 6DOHVSHUVRQ DGGLWLRQVFKDQJHV RI HPSOR\LQJ EURNHU ‡ %URNHU GLVFRQWLQXDWLRQ RI VDOHVSHUVRQ HPSOR\PHQW ‡ 0DLOLQJ DGGUHVV FKDQJHV ‡ %URNHU PDLQ RI¿FH DGGUHVV DGGLWLRQFKDQJHV ‡ $XWRPDWHG IHH SD\PHQW DQG SURFHVVLQJ General Information ¾ ¾ ¾ Type or print clearly in ink (black or blue; do not use red). Business and license mailing addresses are public information and as such are posted on the Internet and available from DRE via telephone and written requests. Please consider this when identifying a license mailing address. If you electronically re-create this form to facilitate completion on a computer, the form should not be altered in any manner. To do so, could result in disciplinary action. Also, please make certain you do not delete any preprinted information and are using the latest version of the form. Broker-Salesperson 0DQ\ UHDO HVWDWH EURNHUV HOHFW WR ZRUN IRU RWKHU EURNHUV LQ D FDSDFLW\ VLPLODU to the relationship existing between a licensed real estate salesperson and an employing broker. However, such broker-salespersons are still licensed by the Department of Real Estate (DRE) as real estate brokers. Only by written agreement with another broker are they acting as broker-salespersons. Section 2726 of the Commissioner’s Regulations requires that “… every real estate broker shall have a written agreement with each of his salesmen, whether licensed as a salesman or as a broker under a broker-salesman arrangement.” Even though a broker may act as a broker-salesperson in a relationship with another broker, for Department of Real Estate licensing and record-keeping purposes the licensee is still a broker. This means that a broker-salesperson should still communicate with DRE using only appropriate broker forms and applications. :KHQ XVLQJ WKH SURSHU EURNHU IRUPV QR UHIHUHQFH VKRXOG EH PDGH WR WKH name RU ¿FWLWLRXV QDPH of the broker for whom the broker-salesperson works. That type of information is irrelevant as there is no reference in the DRE records that such a working relationship exists. It is also imperative that a broker-salesperson speak for himself or herself, meaning that any requests for record changes be made by the broker-salesperson and not by anyone else on his or her behalf. A broker-salesperson should never use salesperson forms or applications when renewing or making changes to a broker record. Doing so will cause delays in processing whatever is requested. Remember — a broker is always a broker regardless of any working relationship that may exist with another broker. PRIVACY INFORMATION: Section 1798.17 of the Civil Code requires this notice be provided when FROOHFWLQJ SHUVRQDO RU FRQ¿GHQWLDO LQIRUPDWLRQ IURP LQGLYLGXDOV (DFK individual has the right to review personal information maintained by this Agency, unless access is exempted by law. 'HSDUWPHQW RI 5HDO (VWDWH 0DQDJLQJ 'HSXW\ &RPP ,9 2201 Broadway Licensing, Examinations, & Education Sacramento, CA 95818 Telephone: 877-373-4542 General powers of the Commissioner, Sections 10050, 10071, and 10075 of the Business and Professions Code authorizes the maintenance of this information. Business and Professions Code Sections 30, 31(e) and 494.5(d) require each real estate licensee to initially provide to the Department of Real Estate his or her social security number which will be furnished to the Franchise Tax Board. The Franchise Tax Board will use your number Mailing Information 7KLV DSSOLFDWLRQ PD\ EH VXEPLWWHG LQ SHUVRQ DW DQ\ GLVWULFW RI¿FH RU PDLOHG WR WKH 6DFUDPHQWR RI¿FH Mail To: Department of Real Estate P.O. Box 187004 Sacramento, CA 95818-7004 WR HVWDEOLVK LGHQWL¿FDWLRQ H[FOXVLYHO\ IRU WD[ SXUSRVHV 7KHVH FRGH sections also require that each application for a new license or renewal SURYLGHV QRWL¿FDWLRQ RQ WKH DSSOLFDWLRQ WKDW WKH %RDUG RI (TXDOL]DWLRQ and the Franchise Tax Board will share taxpayer information with the Department of Real Estate, and that failure to pay tax obligations may result in a suspension or denial of a license. The Board of Equalization and Franchise Tax Board require the Department to collect social VHFXULW\ QXPEHUV DQG IHGHUDO WD[SD\HU LGHQWL¿FDWLRQ QXPEHUV IRU WKH purposes of matching the names of the 500 largest tax delinquencies pursuant to Section 7063 or 19195 of the Revenue and Taxation Code.