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LICENSE RENEWAL APPLICATION

REA 3012 (Rev 2/11/2021) page 1 of 3 LICENSE RENEWAL APPLICATION1. APPLICATION LevelTrainee LICENSE $850 Residential LICENSE $955 Certified Residential $1030 Certified General $10302. Current LicenseLicense NumberExpiration Date3. NameLastFirstMiddle4. Social Security / Individual Taxpayer ID Number5. Birth Date6. Business Name Check if Change7. Mailing Address (Address of Record) Check if Change8. Business Telephone Number9. Residence Telephone NumberAddressCityCounty State Zip CodePART A - APPLICANT INfoRmATIoNBREA USE ONLY Type or print clearly in blue or black ink and provide an original signature.

REA 3012 (Rev 2/11/2021) page 3 of 3 INSTRuCTIONS PART A 1. APPLICATIoN LEVEL - Mark the box for the license type you are renewing. 2. CURRENT LICENSE NU mBER - Your License Number and expiration date. 3.

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