State of Florida

1 1 of 6 DBPR RE 7 Real Estate company Application Effective: Oct 2014 Incorporated by Rule: State of Florida Department of Business and Professional Regulation Florida Real Estate Commission Application for Real Estate company Form # DBPR RE 7 APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your application to ensure faster processing. ALL Applicants must submit: Fee: Submit check in the amount of $ , payable to the Florida Department of Business and Professional Regulation.

2 Please mail your completed application, documentation and required fee(s) to: Department of Business and Professional Regulation 2601 Blair Stone Road Tallahassee, FL 32399-0783 2 of 6 DBPR RE 7 Real Estate company Application Effective: Oct 2014 Incorporated by Rule: State of Florida Department of Business and Professional Regulation Florida Real Estate Commission Application for Real Estate company Form # DBPR RE 7 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at For additional information see Instructions at the end of this application.

3 Section I company Type CHECK ONE OF THE company TYPES Initial Real Estate company License- select one of the company types below: Corporation [2502/1020] Partnership [2503/1020] Professional Association [2502/1020] LLC [2502/1020] Other (please specify): Section II Initial company Information company INFORMATION Federal Employer ID Number: company Name: Doing Business As (D/B/A) Name: MAILING ADDRESS Street Address or Box City State Zip Code (+4 optional) County (if Florida address) Country CONTACT INFORMATION Contact Name.

4 Primary Phone Number Primary E-Mail Address BUSINESS LOCATION ADDRESS Street Address City State Zip Code (+4 optional) County (if Florida address) Country ADDITIONAL CONTACT INFORMATION (OPTIONAL) Alternate Phone Number Fax Number Alternate E-Mail Address 3 of 6 DBPR RE 7 Real Estate company Application Effective: Oct 2014 Incorporated by Rule: Section III Broker Information (attach additional copies of this page if necessary) BROKER INFORMATION NOTE: List all brokers with the company .

5 All Active brokers must be listed as an officer, director, partner, or member manager of the business with the Florida Division of Corporations website Multiple License Request: If a broker listed below is currently qualifying another Real Estate company or Sole Proprietorship and wishes to continue operating as a qualifying broker for that company /sole proprietorship, then a multiple license must be requested. Fee: $77 for each multiple license requested. Note: If you do not request a multiple license, your relationship status with the previous company will be ended.

6 Broker Name and License Number Indicate whether Broker is Active or Inactive Does this person own greater than or equal to 10% of this company ? Request Multiple License : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number.

7 Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: : Active Inactive Yes No Yes No License Number: 4 of 6 DBPR RE 7 Real Estate company Application Effective: Oct 2014 Incorporated by Rule: Section IV Non-Broker Owner Information Note: Please list all non-broker owners of this company holding greater than or equal ( > or = ) to 10% of the company s stock.

8 Name Social Security Number* Address 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United states Code, Sections 653, 654, and 666(a); and Sections (9), , and , Florida Statutes. Social Security numbers must be recorded on all professional and occupational license applications and will be used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations.

9 Section V Affirmation by Written Declaration AFFIRMATION BY WRITTEN DECLARATION I certify that I am empowered to execute this application as required by Section , Florida Statutes. I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license.

10 Signature: Date: Print Name: 5 of 6 DBPR RE 7 Real Estate company Application Effective: Oct 2014 Incorporated by Rule: Instructions If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 1) General Information and Requirements a) The company must have at least one active broker qualifying the company .