Initial Real Estate Broker License Application for Corporation/Partnership/Limited Liability Company Page 2 of 2
4. REGISTERED AGENT FOR SERVICE OF PROCESS:
Preferred Mailing Address _______ ____________________________________
City, State, Zip+4 _______ ____________________________________
Daytime phone number ( ) ___ ___ ___ - ___ ___ ___ ___
5. OFFICERS, DIRECTORS, PARTNERS, MANAGERS, AND PRINCIPLES:
List the names of the officers, directors, partners, managers, and principles who will actively participate in the real
estate business activities of the Corporation, Partnership, or Limited Liability Company in Louisiana. Use a separate
sheet, if necessary.
a. ________________________________________________________________ Broker Salesperson
b. ________________________________________________________________ Broker Salesperson
c. ________________________________________________________________ Broker Salesperson
6. DESIGNATED QUALIFYING BROKER:
The Designated Qualifying Broker is the real estate licensee authorized to apply for a Louisiana Real Estate Broker License on
behalf of and in the name of the herein named Corporation, Partnership, or Limited Liability Company. The Designated Qualifying
Broker shall be the licensee’s representative in all matters relating to its real estate license activities in Louisiana and in all matters
before the Louisiana Real Estate Commission.
Name: _________________________________________ License Number: _____________________________
On behalf of the Corporation, Partnership, or Limited Liability Company: (select only one option)
I elect to participate in the Louisiana Real Estate Commission group errors and omissions
insurance policy coverage, and I have enclosed the required premium.
I elect to obtain independent errors and omissions insurance coverage in lieu of the group policy
and have attached the Verification of Independent Insurance Coverage Form prescribed by the
Louisiana Real Estate Commission.
CERTIFICATION AND ACKNOWLEDGEMENT
I hereby certify that all and singular the facts set forth in the foregoing instrument are true and correct.
Signature of Designated Qualifying Broker:
Print Name: ____________________________________________________ Date: _____________________
InitBrokCPL Rev. 01/2018
I have attached the registration certificate issued by the Secretary of State to the Corporation,
Partnership, or Limited Liability Company.
I have attached a resolution ex
ecuted by a principal of the Corporation, Partnership, or Limited
Liability Company that designates a licensed individual real estate broker as the Qualifying Broker
and that the intent of the company is to conduct real estate activity.
The following two boxes must be checked and corresponding documents attached for form to be valid:
I have attached a copy of the trade name and/or trademark registration certificate issued by the
Secretary of State to the Corporation, Partnership, or Limited Liability Company.
The following box is optional, but if checked the corresponding document must be attached: