COM 3608 (Rev. 4/2017) Page 1 of 1 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 BRANCH OFFICE APPLICATION This form is interactive. You may, before printing, type your responses directly onto the form. Otherwise, this form must be typewritten or printed legibly in black ink. Incomplete applications and applications that are filled out incorrectly will be returned for correction. A check or money order, made payable to the Ohio Division of Real Estate, in the amount of $15.00, must accompany each application. Cash will not be accepted. A principal broker of the real estate company applying for a branch office must sign this application. A separate application is required for each branch office. FOR DIVISION USE ONLY FILE NUMBER APPLICANT INFORMATION COMPANY FILE NUMBER COMPANY NAME DOING BUSINESS AS (D.B.A.) NAME MAIN BUSINESS ADDRESS BUSINESS PHONE CITY STATE ZIP CODE + 4 BRANCH OFFICE INFORMATION NAME OF PRINCIPAL BROKER/MANANGEMENT LEVEL LICENSEE IN CHARGE OF BRANCH OFFICE FILE NUMBER BRANCH OFFICE ADDRESS BRANCH PHONE CITY STATE ZIP CODE + 4 THE APPLICANT 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 and the loss of my Ohio real estate license. NAME OF PRINCIPAL BROKER OF REAL ESTATE COMPANY (PRINT) SIGNATURE OF PRINCIPAL BROKER DATE BROKER FILE NUMBER REPL-17-0014 American LegalNet, Inc. www.FormsWorkFlow.com