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Change Application Individual COM 3628 - Ohio
| Change Application Individual Form. This is a Ohio form and can be used in Broker Real Estate Department Of Commerce Statewide . |
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Ohio Department of Commerce Division of Real Estate & Professional Licensing 77 South High Street · 20 Floor Columbus, OH 43215-6133 (614) 466-4100 FAX (614) 644-0584 www.com.ohio.gov th Governor Director REAL ESTATE CHANGE APPLICATION - INDIVIDUAL FOR DIVISION USE ONLY FEE AMOUNT FILE NUMBER LICENSE RECEIVED BROKER NUMBER ISSUE DATE This form is interactive. You may, before printing, type your responses directly onto the form. Otherwise, this form must be typewritten or printed legibly in black ink. Incomplete applications and applications that are filled out incorrectly will be returned for correction. A check or money order for any fees, made payable to Division of Real Estate & Professional Licensing must be remitted with this form. Cash will not be accepted. REASON FOR COMPLETING THIS FORM (check all that apply) CHANGE HOME ADDRESS (complete sections 1, 2 and 4; no fee. You may also do this online at www.com.state.oh.us/real, click on eLicense Center.) REPLACE LOST OR DAMAGED LICENSE: CHOOSE ONE: ___ REISSUE LICENSE; ___ PLACE LICENSE IN INACTIVE STATUS (complete sections 1 and 2; complete section 4 if applicable; $20 fee.) INDIVIDUAL NAME CHANGE (complete sections1, 2, and 3; submit a copy of the legal document showing the name change; $20 fee.) Return Original License 1. APPLICANT'S FILE FILE NUMBER (* VERY IMPORTANT. The application cannot be processed without this information.) NUMBER LAST NAME FIRST NAME MIDDLE INITIAL OR NAME 2. CURRENT NAME 3. NEW NAME LAST NAME STREET ADDRESS 4. NEW HOME ADDRESS CITY COUNTY FIRST NAME MIDDLE INITIAL OR NAME SUFFIX SUFFIX HOME PHONE ( ) STATE ZIP CODE + 4 THE APPLICANT MUST COMPLETE THE FOLLOWING CERTIFICATION I certify that all of the statements on this application and all of the attached materials are complete and accurate. I understand that any false statement on this form or any of the attached materials may subject me to criminal prosecution and the loss of my Ohio real estate license. ___________________________________ _______________ SIGNATURE OF APPLICANT DATE NOTICE: Evidence that payment has been refused by the drawer's bank upon a check drawn to the order of the Ohio division of real estate shall constitute prima facie evidence of misconduct and shall constitute a violation of division (A)(6) of section 4735.18 of the Revised Code. Page 1 of 1 COM 3628 (Rev. 01/2006) "An Equal Opportunity Employer and Service Provider" American LegalNet, Inc. www.FormsWorkflow.com HAVE YOU FILLED OUT THE FORM CORRECTLY? To avoid any delays in the processing of your application, ask yourself the following questions. By double checking your paperwork in these critical areas, you should be successful! *ARE THE PROPER FEES ATTACHED (CHECK OR MONEY ORDER)? *DID I USE MY LEGAL NAME (AS IT APPEARS ON MY DRIVER'S LICENSE OR MY REAL ESTATE LICENSE)? *DID I LIST MY SOCIAL SECURITY NUMBER, AND INDICATE THE YEAR I GRADUATED FROM HIGH SCHOOL OR COMPLETED THE G.E.D.? (LICENSE EXAMINATION APPLICATIONS ONLY.) *DID I INCLUDE MY LICENSE/FILE NUMBER? (IF APPLICABLE.) *DID I LIST MY DATE OF BIRTH? *DID I LIST THE BROKER'S MAIN ADDRESS AND NOT A BRANCH LOCATION? *DID I COMPLETE THE ETHICAL CONDUCT AND LEGAL HISTORY SECTION? *DID I INCLUDE AN EXPLANATION (OR A JOURNAL ENTRY FOR CONVICTIONS) FOR ANY YES QUESTIONS UNDER THE ETHICAL CONDUCT AND LEGAL HISTORY SECTION? *DID I SIGN MY APPLICATION? *DID MY BROKER (WHO IS IN GOOD STANDING AND ACTIVE WITH THE DIVISION) SIGN MY APPLICATION? (SALESPERSON APPLICATIONS ONLY.) By carefully filling out this application you will speed up the processing time. Every application with deficiencies must be returned, which costs both you and the Division valuable processing time! Pursuant to Ohio Administrative Code 1301:05-1-04, failure to timely submit such corrected application or additional information within thirty (30) days of receiving a deficiency notice shall constitute just cause for the superintendent to impose a forfeiture of the application fee. American LegalNet, Inc. www.FormsWorkflow.com
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