REE-036-11
rev. 07/2020
IREC use only
Approved:
__________________________
575 E. Parkcenter Blvd., Suite 180
Boise, Idaho 83706
Offi ce: (208) 334-3285
Fax: (208) 334-2050
irec.idaho.gov
NOTICE OF PROVIDER
CHANGE
This form is required for any change in provider ownership, provider name, or name
of director (individual in charge). A change must be submitted at least one (1) month
in advance of the eff ective date of the proposed change (Idaho Code 54-2027(9)).
For a change in director, the individual in charge must have attended a commission-approved provider training
within the two (2) years immediately preceding the designation (Idaho Code 54-2026(2)(b)(iii)).
INCOMPLETE FORMS WILL BE IMMEDIATELY RETURNED WITHOUT PROCESSING. FAXED OR
EMAILED FORMS WILL NOT BE ACCEPTED.
Current Name of Provider for which Change is Requested:
_________________________________________________________ ______________________________
Name as it was initially certi ed Provider Director Name
Provider is a (choose one):
Corporation Limited Liability Company Limited Partnership Limited Liability Partnership
1. Change of Provider Director (individual in charge) Date of Provider Training (required): _______________
______________________________________________________ ______________________
Full Legal Name of Provider Director (full legal name must exact match legal ID) Social Security Number (required) Date of Birth
________________________________________________________________________________________
Physical address of Provider
__________________________________________________________ _________________ ___________
City State Zip
________________________________________________________________________________________
Mailing address of Provider (if diff erent from above)
__________________________________________________________ _________________ ___________
City State Zip
_______________ _______________ ___________________________ ____________________________
Phone Fax Email Website
Have you ever had a real estate license or other professional license suspended or revoked for disciplinary reasons or been
refused a renewal of a license issued by any state or jurisdiction?
NO YES (attach explanation and copy of fi nal order/judgment)
Have you ever been convicted, issued any ne, placed on probation, received a withheld judgment, or completed any
sentence of con nement for or on account of any felony or misdemeanor involving fraud, misrepresentation, or dishonest or
dishonorable dealings in a court of proper jurisdiction? (“Convicted” means a plea of nolo contendere or guilty, a jury verdict
of guilty or a court decision of guilt, whether or not a judgment or sentence has been imposed, withheld, or suspended.)
NO YES (attach explanation and copy of fi nal order/judgment)
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