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 APPLICATION - INDIVIDUAL 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. FOR DIVISION USE ONLY Incomplete applications and applications that are filled out incorrectly will be returned for correction. A check or money order for any fees, made payable to Division of Real Estate & Professional Licensing must be remitted with this form. Cash will not be accepted. REASON FOR COMPLETING THIS FORM (check all that apply) CHANGE HOME ADDRESS: (complete sections 1, 2, 3 and 5; no fee. You may also do this online at www.com.ohio.gov/real . Click on eLicense Center. Contact the Division directly to obtain a username and password if you do not have that information.) REPLACE LOST OR DAMAGED LICENSE: CHOOSE ONE: REISSUE LICENSE; PLACE LICENSE IN INACTIVE STATUS (complete sections 1, 2 and 3; complete section 5 if applicable; $25 fee.) INDIVIDUAL NAME CHANGE: (complete sections1, 2, 3 and 4; submit a copy of the legal document showing the name change; $25 fee.) Return Original License CREDENTIAL NUMBER REVERSION: I am an Ohio broker with a previous Ohio salespersons license issued prior to the year 2000 and wish to revert my current credential number back to my previous credential number. (complete sections 1 and 2; no fee) Return Original License OR Company License and Addendum CHANGE LICENSE LEVEL DESIGNATION: (complete sections 1, 3 and 6; principal broker must certify) - Return Original License OR Company License and Addendum $25.00 1. NUMBER FILE NUMBER (* VERY IMPORTANT. The application cannot be processed without this information.) 2. EMAIL ADDRESS EMAIL ADDRESS 3. CURRENT NAME FIRST NAME MIDDLE NAME LAST NAME SUFFIX 4. NEW NAME FIRST NAME MIDDLE NAME LAST NAME SUFFIX 5. NEW HOME ADDRESS STREET ADDRESS PHONE CITY STATE ZIP CODE 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. SIGNATURE OF APPLICANT DATE 6. LICENSE LEVEL DESIGNATION (to be completed by the principal broker, SELECT ONE) PRINCIPAL BROKER MANAGEMENT LEVEL BROKER ASSOCIATE BROKER MANAGEMENT LEVEL SALESPERSON SALESPERSON PRINCIPAL BROKER 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. PRINCIPAL BROKER SIGNATURE DATE NOTICE: one-hundred-dollar fee payable to the superintendent or rejection or withdrawal of approval of this application. REPL-17-0002 COM 3628 An Equal Opportunity Employer and Service Provider Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com