Application to transfer broker or agent between firms. _________[state] REAL ESTATE COMMISSION APPLICATION TO TRANSFER Notice: This form is to be completed only if a licensee is transferring from one firm or broker to another firm or broker. When this transfer form has been completed, it must be mailed or hand delivered with the old license to the Commission without delay within 72 hours. When the completed and correct transfer form and old license are received, a new license will be issued with an effective date of transfer of either 1). the effective date of the new affiliation, or 2). the date of release from the previous broker whichever is later. There are three (3) steps to transfer AND THEY MUST be completed in the order in which they appear on this form. Step # 1 (To be completed by new affiliating broker) Name of transferring licensee _________[Print or Type] Type of license _________[Salesperson or Broker Associate] License number _________ Effective date of new affiliation _________ Business name _________ Name of new broker _________[Print or Type] License number _________ Your Signature _________[New broker] Date: _________ Step # 2 (To be completed by releasing broker) Name of releasing broker _________[Print or Type] License number _________ Business name _________ The license of the transferring individual is attached to this form in compliance with the immediate return of a license to the Commission as required by _________[state] Code section _________, Change of employment.
Your Signature _________[Releasing broker] Date of release: _________ Step # 3 (To be completed by transferring licensee) I, _________[Print name of transferring licensee] hereby certify that the above information is true and correct. I further acknowledge that providing false information on this transfer form would be in violation of _________[state] Code section _________ , Fraud in procuring a license, which could result in disciplinary action against my license. _________[Signature of transferring licensee] Date: _________