Legal Entity Designee Change REV 1_17
Application to Change Designated Broker for a Legal Entity
This application must be accompanied by a check or money order in the amount of $25.00 made payable to
“Treasurer, State of Connecticut”. Please mail the completed application and fee to the above address.
Name of Legal Entity Connecticut Broker License Number
Business Street Address City State Zip Code
Telephone Number Name of Current Designated Broker Email Address
Yes No If Yes, please complete the Affidavit of Ownership Form.
Has the ownership changed for the legal entity?
If ownership has changed have you filed the changes with the Connecticut Secretary of the State’s Office? Yes No
NEW DESIGNATED BROKER INFORMATION
Name of New Designated Broker Email Address
Is the applicant a designee for any other legal entity in Connecticut or maintain an individual Connecticut broker license?
Yes No If Yes, provide all license number(s): __________________________________________________________
Note: A broker may not be the designee for more than one legal entity without holding an individual broker license
Has the new designee ever had a license or certification refused, suspended or revoked in any State? Yes No If yes,
attach a statement providing the state(s) and the details regarding the type of action taken.
Has the new designee ever been convicted of a crime related to forgery, embezzlement, obtaining money under false
pretenses, extortion, criminal conspiracy to defraud, a felony crime or any like offenses?
Yes No If yes, attach a
statement providing the date(s) and nature of conviction(s), where the cases were decided, and a description of the circumstances.
CONSENT FOR SERVICE FOR ALL NON-RESIDENTS
The undersigned ____________________________________________________ county of _________________________________________
State of ____________ I, applicant hereby file irrevocably consent that suits and actions may be commenced against such applicant in the
proper court in any judicial district of the state in which a cause of action may arise or in which the pl
aintiff may reside, and that in the
event proper service of process cannot be made upon such applicant in any such proceeding, service may be made by service of process
or pleading authorized by the laws of Connecticut on the Chairperson of the Connecticut Real Estate Commission, hereby stipulating
and agreeing that such service of such process or pleading upon the said Chairperson of the Connecticut Real Estate Commission shall
be taken and held in all courts to be as valid and binding as if service had been made upon said applicant in the State of Connecticut. In
accordance with Section 20-317(b) CGS.
______________________________________________________________________________ ______________________________
Signature of Applicant Date
CERTIFICATION
STATE OF CONNECTICUT
For Official Use Only
I certify, under penalty of law (C.G.S. section 53a-157b, a Class A Misdemeanor) that the information provided in this
application is the truth to the best of my knowledge.
________________________________________________________________________________ ______________________________
Signature of Applicant Date
DEPARTMENT OF CONSUMER PROTECTION
LICENSE SERVICES DIVISION
450 COLUMBUS BLVD, STE. 801
HARTFORD, CT 06103
Email: dcp.licenseservices@ct.gov
Web site: www.ct.gov/dcp
