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 CHANGE APPLICA T ION - BUSINESS T h is form is i n teracti v e. Y o u m a y, b ef o re pri n ti ng , ty p e y o u r resp on ses d irectly on t o t h e for m . Ot h e rwise, t h is f o rm m u st b e t y p ewritten or pri n ted le g i b ly i n b lack i n k. FEE: $ 25.00 Inco m plete or incorre c t applicati o ns will be returned for corre c tion. FOR DIVISION USE ONLY A c h eck or m on e y or der f o r a n y fee s , m a d e p a y a b le to D i visi o n o f Real Estate & Professi on al Lice n si n g , m u st b e re m i tt ed with t h is f o r m . C a sh will n o t be a ccepted. Do not use th i s form if you are r e gistering a c o mplete l y new company with a new r e gist r a t i on/charter number f r om the Ohio Sec r eta r y of State. Use t h e As so ciation , Corporat i o n, LLC, or P a rtnersh i p Application as a p propriat e . If you ne e d to submit a cha n ge of busine s s addre s s, plea s e use the app r opr i ate C ha n ge of Bus i ness Addre s s f o rm. Please su b m it, with t h is ap p licati on , a c op y o f t h e certifica t e fr o m t h e Secretary o f State t h at pr ov es your bu s i n ess e n tity and na m e certification a re proper l y register e d w i th that office. I f y o u a r e o n ly c h a ng i n g yo u r c o m p a n y n a m e and no t c h an g ing your c h a r t er nu m b er o r y o ur D BA n a m e, p lease su b m it y o ur n ew c o m p a n y n a m e re g i strati o n alo n g with t h is a pp licati o n. REASON FOR COMPLETING THIS FORM (check all that apply) C H A N GE O F BUSINESS ENT I TY N A M E (Co m plete sections 1, 2, 3, 6 and 7 ; su b mit a lett e r from t he bank at w hich t he trust/special account is held that includes the account - holder name, t he a c count number, a nd a statement t hat the account is a non - interest bearing trust or special account; if more t han one b roker o r one or more sa l esperson is involved in this transaction, complete and submit the M ultip l e Lic e nse Trans f er A ffi d a v it [ C OM 3683] ; remit $25 applic a ti o n fe e , $25 fee f o r each salesperson lic e nse and $25 f ee for each brok e r license, not to e x ceed a total of $6,000 . ) Retur n origina l compan y licens e an d addendum. C H A N GE OR E S T A B LI S H NEW FICT I TIOUS OR DOI N G B USIN E SS A S (DB A ) N A M E (C o mplete sections 1, 2, 4, 6 , and 7 ; submit a letter from the b a nk at w hich the t rust/special account is held that includes the account DBA name, the a ccount number, and a stat e ment that the account is a non - interest bearing t rust/special acc o unt; if more t han one broker or o n e or mo r e salesperson is involved in this transacti o n, complete and submit the Mult i ple Licen s e Tr a ns f er A f f i d a v it [ C OM 3683] ; remit $ 25 appl i cat i on f ee , $25 f e e for e ach salesperson license and $25 fee f o r each broker license, n ot t o exc e ed a t otal of $6, 0 00 .) Return original company license and addendum. REP L A C E LO S T OR D A M A G E D LICENS E : C H OOSE ONE : REISSUE LI C ENSE; PL A CE LICENSE IN INACTIVE ST A T US (Complete sections 1, and 2; co m plete section 6 if applicable; $25 fee .) ADD MULTIPLE DBAs (Complete sections 1 , 2, 3, 5 and 7 below; s ubmit this form, along with your Secretary of State filing and trust account information , $25 fee. ) Return original company license and addendum . 1. A PPL I C A N T FILE N U M B ER, COMPANY FI L E NUMBER***, & F E D E R AL TA X ID APPLICANT FILE NUMBER COMPANY FILE NUMBER FEDERAL TAX ID 2. CURRENT BUSINESS ENTITY NAME CURRENT BUSINESS ENTITY NAME AND DBA 3. NEW BUSINESS ENTITY NAME NEW BUSINESS ENTITY NAME 4. NEW FICTITIOUS OR DBA NAME NEW FICTITIOUS OR DBA NAME 5. ADDITIONAL DBA NAME DBA NAME ADDITIONAL DBA NAME DBA NAME ADDITIONAL DBA NAME DBA NAME ADDITIONAL DBA NAME DBA NAME 6 . NEW BUSINE S S A DDRESS BUSINESS ADDRESS BUSINESS PHONE CITY STATE ZIP CODE 7 . Name of appl i c a nt o r b r oke r / o ff i ce r/ member/pa r tner a u thor i z ed to bind same. ( t y pe or pri n t) Signatu r e o f appl ic ant or b rok e r/ o ffice r /member/ p art n er a uthor i z ed to bind same. DATE * * * THIS APPLICATION CANNOT BE PROCESSED WITHOUT THE APPLICANT AND COM P ANY F I LE NUMB E RS. NOT I CE : - hundred - dollar fee payable to the superintendent or rejection or withdrawal of approval of this application . REPL - 17 - 0004 COM 3684 Equal Opportunity Employer and Service Provide r Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com