Arkansas Real Estate Commission
612 South Summit Street
Little Rock, AR 72201-4740
Phone: (501) 683-8010
Fax: (501) 683-8020
NOTICE OF PERSONAL INFORMATION CHANGE
(NAME AND/OR RESIDENCE)
Forms that are incomplete or not accompanied by the proper attachments will be returned to you.
License Number: __________________________ Date of Change: __________________________
(30-day temporary for Name Change only.)
(Indicate Type of Change)
Address Change Name Change
OLD INFORMATION
NEW INFORMATION
Signature of Licensee: _______________________________
NOTE: All licensees, both active and inactive, shall at all times keep the commission informed in writing of
their personal residence address per Regulation 7.6(b). For a personal name change attach legal documentation
of the requested name change (i.e. marriage certificate, divorce decree, legal name change form). Return the
license and pocket card, along with this form, if requesting a name change (A copy of form serves as a
30-day temporary license). (02/2013)
(As it appears on License):________________________________________________________
(First Name) (Middle Name or Initial) (Last Name)
Licensee’s Old Resident Address: ___________________________________________________________
PO Box: _______________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Home Phone (with area code): ____________________________________________________________________
Email Address: __________________________________________________________________________
(As it is to appear on License):_____________________________________________________
(First Name) (Middle Name or Initial) (Last Name)
Licensee’s New Resident Address: __________________________________________________________
P O Box: ______________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Home Phone (with area code): ____________________________________________________________________
Email Address: __________________________________________________________________________
