Revised 1107
DBPR RE-2050 Request for Change of Status
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
1940 North Monroe Street
Tallahassee, FL 32399-0783
Customer Contact Center: 850.487.1395
FAX: 850.488.8040
www.myfloridalicense.com/dbpr
CHECK ACTION(S) REQUESTED
Transaction Type:
Become Active – no charge
Become Inactive – no charge
Add/Delete Trade Name – no charge
Become Sole Proprietor – no charge (Forms 2050 & 0080 required)
Change Broker/Owner Employer – no charge
Terminate Employee – no charge
Add/Delete PA or LLC - $30.00 fee required – see F.S. 475.161
Request for Multiple License - $95.00
Renew license
Qualifying Broker (CQ package required)
Owner/Developer (Forms 2050 & 0080 required)
ASSOCIATE INFORMATION
License Number Licensee Name
Contact Information (telephone number or E-Mail address)
BROKER OR ORGANIZATION INFORMATION
Broker License Number Organization License Number
Broker/Owner Name
Organization Name
Trade Name (if applicable) Contact Info. (telephone number or E-Mail address)
Are you now or with the issuance of this license, an officer, director, member, or partner of any
corporation, partnership, or L.L.C. which acts as a broker? Yes No
If yes, please list name of entity
ATTEST STATEMENT
REQUIRES SIGNATURE OF BROKER
AND ASSOCIATE*
(Except for Add/Delete PA or LLC – which may be signed by the licensee)
I affirm that I have provided the above information completely and truthfully to the best of my
knowledge.
Broker/Owner Sign Here: ___________________________________________ Date: ______________
*Broker signature not req. for Assoc. inactive status or add/delete PA –LLC
Print Broker/Owner Name: ______________________________________________________________
Associate Sign Here: ______________________________________________ Date: ______________
*All Associate requested changes require signature
RE-2050 Request for Chng of Status
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome