CORPORATION, PARTNERSHIP, OR LIMITED LIABILITY COMPANY

CHANGE OF DESIGNATED QUALIFYING BROKER (Complete this form online or print in blue or black ink)

Processing Fee ………………. $35.00

A. Corporation, Partnership, or Limited Liability Company

Name: _______________________________________________________________________________

Owner, Officer, Director, Manager, Partner, or Principle _____________________________________

Street address: ________________________________________________________________________

City, state, zip+4: ______________________________________________________________________

License number: _______________________________________________________________________

Area Code and Phone number: _____________________

B. Current Designated Qualifying Broker for the Corporation, Partnership, or L.L.C.

Name: _______________________________________________________________________________

Street address: ________________________________________________________________________

City, state, zip+4: ______________________________________________________________________

License number: _______________________________________________________________________

Area Code and Phone number: _____________________

C. New Designated Qualifying Broker for the Corporation, Partnership, or Limited Liability Company

Name: _______________________________________________________________________________

Street address: ________________________________________________________________________

City, state, zip+4: ______________________________________________________________________

License number: _______________________________________________________________________

Area Code and Phone number: _____________________

Signature of New Designated Qualifying Broker: ____________________________________________

ACKNOWLEDGEMENT

I hereby certify that I am authorized, on behalf of the herein named Corporation, Partnership, or Limited Liability Company, to change the designated qualifying broker as submitted.

Owner, Officer, Director, Manager, Partner, or Principle: ______________________________________

Signature: ____________________________________________________________________________

LREC ● 9071 Interline Ave ● Baton Rouge, LA 70809 • (225) 925-1923 or (800) 821-4529 (LA only)

CQB 07/2014