State of Utah
Department of Commerce
Division of Real Estate
DUAL BROKER LICENSE APPLICATION
160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov
Please complete (type or neatly print), sign and submit this form along with the non-refundable $118.00 application fee, and any
necessary company registration documentation to the Division by fax, mail, or in person.
Full Name: _________________________________________________________________________________________________
Current License Number: _____________________________ Home Ph: _____________________ Fax: _____________________
Broker email: ______________________________________ Work Ph: ______________________ Cell: _____________________
Broker Physical Address: ______________________________________________________________________________________
__________________________________________________________________________________________________________
Broker Mailing Address: ______________________________________________________________________________________
__________________________________________________________________________________________________________
Real Estate Sales Company Name: ______________________________________________________________________________
Company Number: __________________________________ Phone: ________________________ Fax: _____________________
Company Physical Address: ___________________________________________________________________________________
__________________________________________________________________________________________________________
Company Mailing Address: ____________________________________________________________________________________
__________________________________________________________________________________________________________
Property Management Company Name: __________________________________________________________________________
Company Number: __________________________________ Phone: ________________________ Fax: _____________________
Company Physical Address: ___________________________________________________________________________________
__________________________________________________________________________________________________________
Company Mailing Address: ____________________________________________________________________________________
__________________________________________________________________________________________________________
I certify under penalty of perjury that I am:
□ A United States citizen, with Social Security Number: _____________________________
or
□ A qualified alien under 8 U.S.C. 1641 and am present in the U.S. lawfully.
I-94 Number: ___________________________ or Alien Registration Number: _________________________
I hereby certify that the information provided with this application is true and correct.
Signature _______________________________________________________________________ Date ______________________
( ) Check ( ) Visa ( ) MasterCard ( ) American Express
Make checks payable to: Utah Division of Real Estate
Card #: _______________________________________ Expiration: ____________
Signature ____________________________________________________________
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