Fillable MAILING ADDRESS* SALESPERSON INFORMATION Refer to information on (California Department of Real Estate)

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MAILING ADDRESS* SALESPERSON INFORMATION Refer to information on (California Department of Real Estate)

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  • 8 check-boxes
  • 27 other fields

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



DRE RECEIVED DATE


Read instructions on reverse side before
completing.
Note:
eLicensing
Refer to information on page 2.
TYPE OF CHANGE [Check appropriate box(es)]
RESPONSIBLE BROKER/CORP.*
AFFILIATION DISCONTINUED
PERSONAL NAME
MAILING ADDRESS*
TELEPHONE/EMAIL ADDRESS*
ACTIVATION*
SALESPERSON INFORMATION
1. LICENSE IDENTIFICATION NUMBER DRE USE ONLY
2. SALESPERSON NAME — AS IT APPEARS ON LICENSE. — LAST, FIRST, MIDDLE, SUFFIX
3. SALESPERSON NEW NAME (IF CHANGING) — LAST, FIRST, MIDDLE, SUFFIX (SEE INSTRUCTIONS ON REVERSE SIDE; SIGN LINE #11 WITH NEW NAME.)
4. SALESPERSON MAILING ADDRESS — STREET ADDRESS/P.O. BOX, CITY, STATE, ZIP CODE
5. DO YOU RESIDE IN CALIFORNIA?
YES NO IF NO, FORM RE 234 MUST BE ON FILE WITH THIS DEPARTMENT. SEE REVERSE SIDE.
6. SALES. LICENSE EXPIRATION DATE 7. CURRENT TELEPHONE NUMBER
( )
8. CURRENT EMAIL ADDRESS
MONTH DAY YEAR
9. BUSINESS CELL PHONE NUMBER
( )
10. BUSINESS TELEPHONE NUMBER
( )
SALESPERSON CERTIFICATION
I HEREBY CERTIFY THAT A) THE INFORMATION ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, B) I HAVE COMPLIED WITH §10161.8(C)
AND (D) OF THE BUSINESS AND PROFESSIONS CODE, AND C) I HAVE GIVEN NOTICE OF TERMINATION OF AFFILIATION TO THE BROKER IDENTIFIED ON LINE #22.
11. SIGNATURE OF SALESPERSON — MUST BE ORIGINAL OR ELECTRONIC* SIGNATURE
@
DATE
* Electronic signature must comply with California Uniform Transactions Act (CA Civ. Code section 1633.1 et.seq.)
NEW RESPONSIBLE BROKER/CORPORATION INFORMATION
12. BROKER/CORPORATION ID NUMBER DRE USE ONLY 13. SALESPERSON AFFILIATION DATE DRE USE ONLY
14. BROKER/CORPORATION NAME — AS IT APPEARS ON LICENSE; NO DBA’S
15. MAIN OFFICE ADDRESS OF BROKER/CORP. — STREET ADDRESS, CITY, STATE, ZIP CODE
RESPONSIBLE BROKER CERTIFICATION
I HEREBY CERTIFY THAT A) THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, AND B) THERE IS A WRITTEN AGREEMENT WITH THIS
SALESPERSON ON FILE IN MY OFFICE AS REQUIRED BY §2726 OF THE COMMISSIONER’S REGULATIONS.
16.
SIGNATURE OF NEW BROKER/LICENSED OFFICER — MUST BE ORIGINAL OR ELECTRONIC* SIGNATURE
@
DATE
* Electronic signature must comply with California Uniform Transactions Act (CA Civ. Code section 1633.1 et.seq.)
17. PRINTED NAME OF #16 SIGNER 18. BROKER/CORP. EXPIRATION DATE 19. BUSINESS TELEPHONE NUMBER
FORMER BROKER/CORPORATION INFORMATION
20. BROKER/CORPORATION ID NUMBER. 21. DATE SALESPERSON AFFILIATION DISCONTINUED
22. BROKER/CORPORATION NAME — AS IT APPEARS ON LICENSE; NO DBA’S
23. SIGNATURE OF FORMER BROKER/LICENSED OFFICER
@
DATE
DRE USE ONLY
PROC. # DATE PROCESSED SENDER’S # DATE SENT FORM LETTER/COMMENTS DOCUMENT DATE USED & TYPE (circle one)
RD AD KD
DRE USE ONLY
DRE USE ONLY
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 



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



Type of Change
     



 
 
 (required)
(optional)
 
 
Change of Personal Name      

      

Duplicate License       

Mailing Address(post oce box, residence
or business address) 
(in care of)

Non-California Residents       
          

Mailing Information


Mail To: 


Note To Responsible Broker/Corporation
Responsible Broker/Corporation ID# and Name    
           

 

 


 
RE 214 — Reverse


       


 
 
 






      
        


  


         
        
          





         

          



          




         
        
       
       
      

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MAILING ADDRESS* SALESPERSON INFORMATION Refer to information on (California Department of Real Estate)

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Completed 24 February 2022

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