Louisiana Real Estate Commission
Post Office Box 14785
Baton Rouge, LA 70898-4785
(225) 925-1923 or (800) 821-4529 (LA only)
Fax (225) 925-4501
NICKNAME REQUEST FORM
This form shall be used to add a nickname to your individual real estate license. Changes to your legal
name must be completed using the Name Change Affidavit Form.
Name and trade name changes or additions on a company license must be completed using the
Company Name Change Form.
CURRENT LICENSE INFORMATION
License number: __________________________________________________________________
Name on license: __________________________________________________________________
City, state, zip: __________________________________________________________________
REQUEST TO ADD NICKNAME ON LICENSE
Your legal name is required to be on file with the LREC and printed on your license. A nickname may
be added; however, it must always be used in conjunction with your legal last name.
Nickname as you wish for it to appear on your license:
By signature below, I hereby authorize the Louisiana Real Estate Commission to make the requested
name change. I understand that all advertising, marketing campaigns, and license activities cannot be
conducted in any name(s) other than that listed on my license. If the requested name change does not
meet the requirements of the license law and rules and regulations of the commission, I understand that
this request may be denied until such time that the name change is in compliance.
Signature of licensee