Anne M. Woody Executive Director
Shepherd Mall 2401 NW 23rd Street, Suite 18 Oklahoma City, OK 73107-2431 Telephone (405) 521-3387 Website: www.orec.state.ok.us
“Dedicated To Providing Quality Customer Service”
OKLAHOMA REAL ESTATE COMMISSION
CHANGE NAME For INACTIVE STATUS LICENSEE
Type or print clearly. Please use blue or black ink only. Fee: None
License Number _____________________________
I request my name be changed FROM:
____________________
Last Name
_____________________
First
___________________
Middle
TO: ____________________
Last Name
______________________
First
___________________
Middle
Home Mailing Address _______________________________________________________
_______________________________________________________________________ (City) (State ) (Zip + 4)
Home Telephone Number (____) ________________ e-mail address ________________
Signature ___________________________
Date _____________________
IMPORTANT If you desire an inactive pocket card, remit seven dollars and fifty cents ($7.50) with this completed form. A new pocket card will be issued and mailed to the above home mailing address.
THIS SPACE FOR OREC USE ONLY
OREC RW4501d Change Name of INACTIVE Status Licensee (Rev. 02/02)