Free 47478.FH11 - Indiana

APPLICATION FORREASSIGNMENT OF REAL ESTATE LICENSE
State Form 47478 (R4 / 12-08) Approved by State Board of Accounts, 2009

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INDIANA REAL ESTATE COMMISSION PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317)-234-3009 www.pla.in.gov

INSTRUCTIONS:

For information on how to complete this application, including all applicable fees, please visit our website at www.pla.in.gov.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it. Social Security numbers are available to the Indiana Department of Revenue.

FOR OFFICE USE ONLY
Application fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year) Receipt number License obtained by

DO NOT WRITE ABOVE THIS LINE

Type of application (check one)

Transfer

Transfer to State

Transfer as referral status

Broker to hold own license

SECTION A - TRANSFERRING SALESPERSON OR ASSOCIATE BROKER
Name of licensee Address (number and street, city, state, and ZIP code) License number Social Security number T elephone number

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I hereby swear or affirm that I have notified the releasing broker or corporation / partnership / LLC of my intentions to associate with another broker or corporation / partnership / LLC.
Signature of licensee Date (month, day, year)

SECTION B - TERMINATION OF ASSIGNMENT BY BROKER OR CORPORATION / PARTNERSHIP / LLC
Name of corporation / partnership / LLC Name of releasing broker Address (number and street, city, state, and ZIP code) Signature of releasing broker or principal broker of the corporation / partnership / LLC License number of corporation / partnership / LLC License number of releasing broker Social Security number of releasing broker * T elephone number

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Date (month, day, year)

SECTION C - TRANSFERRING INFORMATION The requesting broker / corporation / partnership / LLC named below requests the license of the salesperson or associate broker to be assigned to its license and has the full responsibility for the salespersons or associate brokers actions in real estate transactions while associated with the requesting broker / corporation / partnership / LLC.
Name of requesting corporation / partnership / LLC Name of principal broker for corporation / partnership / LLC Address (number and street, city, state, and ZIP code) Signature of requesting principal broker License number of corporation / partnership / LLC License number of principal broker Social Security number of principal broker * T elephone number

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Date (month, day, year)