Complete this form only if the company in question has a new charter number issued by the Ohio Secretary If you are changing a co name and the Ohio Secretary of issues the same charter number as your previous company, use the Business [COM 3684form to complete your request. FEE: $100 FOR DIVISION USE ONLY FILE NUMBER Pl Please visit our website at www.com.ohio.gov/real 614|466 - 4100 Fax: 614|644 - 0584 TTY/TDD: 800|750 - 0750 Anne M. Petit , Superintendent REAL ESTATE ASSOCIATION APPLICATION This form is interactive; type the required information into the form, print, sign, date and forward to the Division for processing. A check or money order for $100.00 made payable to: Division of Real Estate & Professional Licensing, must be remitted with this form. Cash will not be accepted. This form may also be typewritten or handwritten (legibly to prevent delays in processing - black ink). NOTE: Incomplete applications and applications that are filled out incorrectly will be returned for correction. COMPLETE THE STEPS BELOW BEFORE SUBMITTING THIS FORM TO THE DIVISION Prior to submitting this application, a new association must have its Doing Business As (DBA) name approved by the Superintendent and the Secretary of State. A name may be reserved by completing the Name Reservation Application Business [COM 3044]. Once your business name has been properly registered, complete this form and attach the following documents: 1) a copy of the association certificate from the Secretary of State (this proves the association is properly registered); 2) a list of all members or officers in the association; 3) an original signed affidavit from any member or officer who is not a principal broker or management level licensee that states he/she will not act as a principal broker or management level licensee for the association; 4) a letter from the bank in which the compspecial account is held that includes the account DBA name, account number, and a statement that the account is a non-interest bearing trust or special account. Non- residents of Ohio must attach the Non-Resident Real Estate Applicannsent to Service of Process [COM 3637]. To transfer more than one broker or one or more salespersons into this association from another entity, complete and attach the Multiple License Transfer Affidavit [COM 3683]. NOTE: This application and the information contained therein, except for social security numbers and trust or special account numbers, is public record pursuant to O.R.C. 149.43. NOTE: New Brokers Your original salesperson license must be returned before your broker license will be issued. If you have just passed both parts of the broker examination, you must submit a Broker Transfer/Reactivation Application [COM 3576] to activate your broker license. An existing Broker or other Business Entity license must be returned before the association license will be issued. ASSOCI A TI O N IN F O R M A T ION NAME OF ASSOCIAT I ON DO I N G BUS I NESS AS ( DBA ) N A M E F E D E R AL TA X ID NUM BER MAIN BU S I NESS ADDRESS CITY STA T E ZIP CODE + 4 BUSINESS PHO N E PRESIDENT FULL NAME VICE PRESIDENT FULL NAME SECRETARY FU L L NAME TREASURER FULL NAME TRUST OR SP E C I A L A CC O U N T IN F O R M A T ION BANK NAME ACCOUNT NAME ACCOUNT NUM B ER BANK ADDRESS CITY STATE ZIP CODE + 4 THE PRINCIPAL B R OKER W HO W I L L A C T ON B EH A L F O F A N D I N THE N A M E OF THE A PPLI C A N T MU S T C O MPLETE T HE F O L L O W I N G CERTIF I C A TIO N I certify that all of the statements on this application and all of the attached materials are complete and accurate. I understand that any false statement on this form or any of the attached materials may subject me to criminal prosecution and the loss of my Ohio real estate license. NAME OF PRINCIPAL BROKER (TYPED OR PRINTED) BROKER FILE NUMBER SIGNATURE OF PRINCIPAL BROKER DATE THE COMPANY MEMBER/OFFICER AUTHORIZED TO BIND THE APPLICANT/ASSOCIATION MUST COMPLETE THE FOLLOWING CERTIFICATION I certify that all of the statements on this application and all of the attached materials are complete and accurate. I understand that any false statement on this form or any of the attached materials may subject me to criminal prosecution. NAME OF OFFICER (TYPED OR PRINTED) SIGNATURE OF OFFICER DATE REPL-17-0007 COM 3509 Equal Opportunity Employer and Service Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com