Fillable CHANGE FORM FOR A PROVISIONAL COMMUNITY MANAGER (Nevada Real Estate Division)

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CHANGE FORM FOR A PROVISIONAL COMMUNITY MANAGER (Nevada Real Estate Division)

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STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
REAL ESTATE DIVISION
3300 W. Sahara Ave., Suite 350, Las Vegas, Nevada 89102 * (702) 486-4033
e-mail: realest@red.nv.gov * http://red.nv.gov/
03/20/2017 1 616A
CHANGE FORM FOR A PROVISIONAL COMMUNITY MANAGER
INSTRUCTIONS:
The Division must receive the original certificate and pocket card.
Complete only the areas that are specific to this transaction and a fee of $20.00 per section per certificate are required.
Payments are accepted in the form of check, cashier’s check, money order (made payable to NRED) or exact cash.
All applicants are required to answer and sign section 3 along with the supervisor signature in section 4.
Incomplete paperwork will not be processed and will be returned to you for completion.
Certificate number :
Date:
Name: (Please print):
First Middle Last (Suffix-if applicable)
Home address:
Phone:
Email address:
1. $20
CHANGE OF SUPERVISOR:
Supervising CAM:
Certificate no. - CAM.
.SUPR
Company Name:
Address:
2. $20
PERSONAL NAME CHANGE: List the name on your current certificate at the top and list your new name here. Proof is required in
the form of a Divorce decree, Marriage Certificate, or a Judgment issued by the court.
New Name:
3.
SIGNATURE of PROVISIONAL COMMUNITY MANAGER :
Have you had any disciplinary sanctions imposed by any regulatory agency or commission within the past 5 years?
NO YES (If Yes, attach a written explanation and the final disposition.)
SIGNATURE of Provisional Community Manager X___________________________________________.
4. SIGNATURE of SUPERVISING COMMUNITY MANAGER.
This is to verify that I am a duly certified Supervising Community Manager on active status registered with the Nevada Real Estate Division of the
Department of Business and Industry. It is my present intent to employ or associate with me the within named Provisional Community Manager: (print
CAM.PROV name here) _________________________________. I will exercise careful supervision over his/her Community manager activities while
he/she is associated with or employed by me.
______________________________________________________ X_______________________________________________________________________
(Print name) (Signature of Supervising Community Manager)
Division only: Date: __________________ Receipt: _________________________ Initials: ____________
03/20/2017 2 616A
REPORT OF EXISTENCE OF NEVADA BUSINESS LICENSE
Pursuant to NRS 116A.435
All applicants MUST complete this section. Please select ONE option.
I have a Nevada business license number assigned by the Nevada Secretary of State upon compliance
with the provisions of NRS Chapter 76.
My Nevada business license number is: _______________________________________
I have applied for a Nevada business license with the Nevada Secretary of State upon compliance with
the provision of NRS Chapter 76 and my application is pending.
I do NOT have a Nevada business license number.
The Real Estate Division is not the arbiter of determining whether the applicant needs a business license.
Information about the Nevada business license can be found on the Secretary of State’s website at:
http://nvsos.gov/
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CHANGE FORM FOR A PROVISIONAL COMMUNITY MANAGER (Nevada Real Estate Division)

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Completed 28 December 2021

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