CORPORATION, PARTNERSHIP, OR LIMITED LIABILITY COMPANY
CHANGE OF DESIGNATED QUALIFYING BROKER
(Complete this form online or print in blue or black ink)
Processing Fee ………………. $35.00
A. Corporation, Partnership, or Limited Liability Company
Name: _______________________________________________________________________________
Owner, Officer, Director, Manager, Partner, or Principle _____________________________________
Street address: ________________________________________________________________________
City, state, zip+4: ______________________________________________________________________
License number: _______________________________________________________________________
Area Code and Phone number: _____________________
B. Current Designated Qualifying Broker for the Corporation, Partnership, or L.L.C.
Name: _______________________________________________________________________________
Street address: ________________________________________________________________________
City, state, zip+4: ______________________________________________________________________
License number: _______________________________________________________________________
Area Code and Phone number: _____________________
C. New Designated Qualifying Broker for the Corporation, Partnership, or Limited Liability Company
Name: _______________________________________________________________________________
Street address: ________________________________________________________________________
City, state, zip+4: ______________________________________________________________________
License number: _______________________________________________________________________
Area Code and Phone number: _____________________
Signature of New Designated Qualifying Broker: ____________________________________________
ACKNOWLEDGEMENT
I hereby certify that I am authorized, on behalf of the herein named Corporation, Partnership, or Limited
Liability Company, to change the designated qualifying broker as submitted.
Owner, Officer, Director, Manager, Partner, or Principle: ______________________________________
Signature: ____________________________________________________________________________
LREC 9071 Interline Ave Baton Rouge, LA 70809 (225) 925-1923 or (800) 821-4529 (LA only)
CQB 07/2014
CLEAR FORM