STATE OF CALIFORNIA DEPARTMENT OF REAL ESTATE Serving Californians Since 1917 CORPORATION CHANGE APPLICATION RE 204A (Rev. 6/09) Received Date 9 Read instructions on pages 3 and 4 before completing this application. CORPORATION CHANGES MAILING ADDRESS CHANGE MAIN OFFICE ADDRESS CHANGE 9 Type or print clearly in black or blue ink. CORPORATION NAME ACTIVATION ADD/CANCEL FICTITIOUS BUSINESS NAME 9 Indicate the type of change(s) by marking one or more boxes in the adjacent column. DESIGNATED OFFICER BROKER-OFFICER CHANGES OFFICER’S PERSONAL NAME ACTIVATION OF OFFICER CORPORATION INFORMATION 1. CORPORATION ID# 2. CORPORATION NAME — PRINT EXACTLY AS SHOWN ON LICENSE CERTIFICATE. 3. NEW CORPORATION NAME, IF CHANGING — PRINT AS SHOWN ON AMENDED ARTICLES OF INCORPORATION 4. CORPORATION MAILING ADDRESS — STREET ADDRESS OR POST OFFICE BOX, CITY, STATE, ZIP CODE 5. CORPORATION MAIN OFFICE ADDRESS — STREET ADDRESS, CITY, STATE, ZIP CODE 6. DRE USE ONLY — EFF. DATE OF CHANGE FICTITIOUS BUSINESS NAME, IF ADDING OR CANCELING — PRINT AS IT APPEARS ON COUNTY CLERK’S FILING. CORPORATION CHANGES ADD CANCEL ADD CANCEL TRANSFER “DESIGNATED OFFICER” TITLE TO ANOTHER “LICENSED OFFICER” 7A. NAME OF CURRENT DESIGNATED OFFICER CORPORATE OFFICER TITLE, IF REMAINING WITH CORP. 7B. CURRENT DESIGNATED OFFICER — CHECK ONE STATEMENT I AM REMAINING WITH THE FIRM AS A LICENSED OFFICER. I AM NOT REMAINING WITH THE FIRM AS A LICENSED OFFICER. 7C. SIGNATURE OF CURRENT DESIGNATED OFFICER DATE ¾ 7D. NAME OF NEW DESIGNATED OFFICER 7E. CORPORATE OFFICER TITLE 7F. SIGNATURE OF NEW DESIGNATED OFFICER DATE ¾ LICENSED BROKER-OFFICER CHANGES 8. 9. DRE USE ONLY OFFICER’S NAME — PRINT AS SHOWN ON LICENSE CERTIFICATE OFFICER’S NEW NAME, IF CHANGING — LAST, FIRST, MIDDLE 10. DO YOU RESIDE IN CALIFORNIA?............................................................................................................................................ YES NO IF NO, AN “RE 234” MAY BE REQUIRED. SEE PAGE 3. 11. BUSINESS TELEPHONE NUMBER (INCLUDE AREA CODE) 12. RESIDENCE TELEPHONE NUMBER (INCLUDE AREA CODE) LICENSED BROKER-OFFICER APPROVAL 13. SIGNATURE OF LICENSED BROKER-OFFICER DATE ¾ DRE USE ONLY EXPIRATION DATE FLAG CLEARANCE PROC. # DATE PROCESSED Continued on reverse side American LegalNet, Inc. www.FormsWorkFlow.com RE 204A Page 2 of 4 REGULATION 2746 Corporate Real Estate Brokers, Officers, Directors and Shareholders (a) At the time of application for, or in the reinstatement of, an original real estate broker license, the designated officer shall file a background statement of information for each director, the chief executive officer, the president, first level vice presidents, secretary, chief financial officer, subordinate officers with responsibility for forming policy of the corporation and all natural persons owning or controlling more than ten percent of its shares, if such person has been the subject of any of the following: (1) Received an order or judgment issued by a court or governmental agency during the preceding 10 years temporarily or permanently restraining or enjoining any business conduct, practice or employment; (2) Has had a license to engage in or practice real estate or other regulated profession, occupation or vocation denied, suspended or revoked during the preceding 10 years; (3) Engaged in acts requiring a real estate license of any state without the benefit of a valid license or permit authorizing that conduct during the preceding 10 years which have been enjoined by a court of law or administrative tribunal; (4) Been convicted of a crime which is substantially related to the qualifications, functions or duties of a licensee of the Department as specified in Section 2910 of these Regulations (excluding drunk driving, reckless driving and speeding violations). (b) The background statement shall be set forth in DRE Form 212 and shall inquire only about the information to be disclosed pursuant to subdivision (a). The background statement must be verified and completed by each corporate officer, director or stockholder as named in subdivision (a) to the fullest extent of the signatory’s actual knowledge. (c) Whenever there is a change in the person whose background statements are required to be on file with the Department for a corporate licensee pursuant to subdivision (a) or an addition to the persons required to file statements pursuant to subdivision (a), the designated officer of the corporation shall, within 30 days thereafter file with the Department a background statement of information for each new or changed person. Note: Authority cited: Section 10080, Business and Professions Code. Reference: Section 10152, Business and Professions Code. CERTIFICATION I certify that I have read and understand the provisions described above. (check one) I also certify that a Corporation Background Statement (RE 212) is not needed for any officers or persons owning or controlling more than ten percent of the corporation shares including myself. A completed Corporation Background Statement(s) is attached for each officer, director or shareholder with a reportable item under Regulation 2746. 14. CORPORATE NAME 15. SIGNATURE OF OFFICER APPLICANT » 16. DATE American LegalNet, Inc. www.FormsWorkFlow.com RE 204A General Information 9 Read the following information before completing this application. 9 If the new designated officer does not currently have an officer license for this corporation, a Corporation License Application (RE 201) must be submitted in addition to this form. 9 Corporation Background Statement (RE 212) – Commissioner's Regulation 2746 requires the designated officer who obtains the original corporation license to file an RE 212 for any director, chief executive officer, president, first level vice presidents, secretary, chief financial officer and subordinate officers with responsibility for forming policy of the corporation and all natural persons owning or controlling more than ten percent of its shares, IF such a person has been subject of any of the items enumerated in the regulation. If none of the officers have been a subject of any of the items enumerated in the regulation, then an RE 212 is not needed. In all instances, the broker-officer must complete and sign the certification on page 2 of this application. 9 Business and 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. 9 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. Type of Change Check the appropriate box(es) on page 1 and complete all requested information. Change of Corporation Name — Enter the new name exactly as it appears on the amended Articles of Incorporation. A copy of the amended Articles of Incorporation showing the endorsement of the Secretary of State must also be included. Mailing Address — The mailing address (post office box, residence or business address) is used to mail correspondence directly to the corporation. Non-California Residents — If residing outside the State of California, a Consent To Service Of Process (RE 234) is also required. If not maintaining an office in California, submit an Out-of-State Broker Acknowledgment (RE 235). Page 3 of 4 Main Office Address — Enter the new primary business location. The main office address must be located in California. If a street address is unavailable, indicate the physical location (i.e., the nearest intersection and the distance to it). If the corporation is no longer working in real estate for which a California license is required, enter “no business address” on line #5. Fictitious Business Name — To add a DBA, enter the name exactly as it appears on the Fictitious Business Name Statement (FBNS) as filed with the County Clerk. The corporation name must be listed as the registrant. The FBNS must be filed in the county where your main office is located. Submit a copy of the FBNS with the “filed stamp” from the County Clerk’s office. • Prior to filing your fictitious business name statement with the county, you may wish to check our Web site (www.dre.ca.gov) to determine if the name is already in use by another broker. • Proof of Publication is not acceptable, unless it bears the County Clerk’s “filed stamp.” • Legible photocopies are acceptable. • This form may be used to add or cancel one or more DBA’s. • FBNS must be refiled if the corporation name is being changed. To cancel a DBA, enter the name and check the cancel box. Change of Officer’s Personal Name — Enter full new name (do not refer to any DBA or company name). Any name change affects all licenses held. Attach verification of name change (i.e., legible copy of drivers license, marriage certificate, court order, etc.). Sign this form with your new name. Transfer “Designated Officer” Title to Another Licensed Officer Complete Items #7a–7e. The current (resigning) designated officer must sign this form as the resigning designated officer or one of the following documents must be attached: • a personally signed resignation letter, • a copy of the Resolution of the Board with the corporate seal, • a signed statement giving the date of death of the designated officer. If the new designated officer does not currently have an officer license for this corporation, a Corporation License Application (RE 201) must be submitted in addition to this form. American LegalNet, Inc. www.FormsWorkFlow.com RE 204A License Certificates A license certificate is automatically generated at no charge for the following transactions: • Change of designated officer or requests for corporation or officer name change. • Adding/deleting fictitious business names. Mailing Information This application may be submitted in person at any district office or mailed to the Sacramento office. Mail To: Department of Real Estate P.O. Box 187004 Sacramento, CA 95818-7004 Page 4 of 4 PRIVACY INFORMATION: Section 1798.17 of the Civil Code requires this notice be provided when collecting personal or confidential information from individuals. Each individual has the right to review personal information maintained by this Agency, unless access is exempted by law. Department of Real Estate Managing Deputy Comm. IV 2201 Broadway Licensing, Exam., & 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 Section 30, Chapter 1361, Section 1, requires 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. Your social security number shall not be deemed a public record and shall not be open to the public for inspection. The Franchise Tax Board will use your number to establish identification exclusively for tax purposes. The Real Estate Law and the Regulations of the Commissioner require applicants to provide the Department with specific information. If all or any part of the required information is not provided, processing may be delayed. In addition, the Commissioner may suspend or revoke a license, or in the case of a license applicant, may deny the issuance for misstatements of facts (including a failure to disclose a material fact) in an application for a license. The information requested in this form is primarily used to furnish license status information to the Department’s Enforcement Section, and to answer inquiries and give information to the public on license status, mailing and business addresses and actions taken to deny, revoke, restrict or suspend licenses for cause. This information may be transferred to real estate licensing agencies in other states, law enforcement agencies (City Police, Sheriff’s Departments, District Attorneys, Attorney General, F.B.I.), and any other regulatory agencies (i.e., Department of Corporations, Department of Insurance, Department of Consumer Affairs, California Bar Association). American LegalNet, Inc. www.FormsWorkFlow.com