Free 00934.PDF - Indiana

FOR OFFICE USE ONLY

APPLICATION FOR REAL ESTATE LICENSE AS PARTNERSHIP OR D / B / A
State Form 934 (R7 / 2-97) Approved by State Board of Accounts, 1990

License number

Check digit

Date granted

County code number

Date license mailed

Control number

INSTRUCTIONS:

1. Mail fifty dollar ($50.00) License Fee to: Indiana Professional Licensing Agency 302 W. Washington St., Rm. E034 Indianapolis, IN 46204 SOLE OWNER - NO FEE PARTNERSHIP - $50.00 Personal and Company checks cause a 2 week processing delay.

COMPANY INFORMATION
Name of company Check one Partnership Address (Number and street, or rural route, city, state, Zip code) Sole Owner DBA County

LICENSE NUMBER

NAME(S) OF PARTNERS OR SOLE OWNER

CHECK ONE Partner Sole Owner Partner Sole Owner Partner Sole Owner

RESIDENTIAL ADDRESS

LICENSE NUMBER

NAME OF PRINCIPAL BROKER

CHECK ONE Partner Sole Owner

RESIDENTIAL ADDRESS

LICENSE NUMBER

NAME(S) OF SALESPERSONS AND BROKERS

CHECK ONLY ONE Salesperson Broker Salesperson Broker Salesperson Broker Salesperson Broker Salesperson Broker

RESIDENTIAL ADDRESS

Signature of Partner or Sole Owner

Date

Telephone number

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