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

CORPORATION, PARTNERSHIP, OR LIMITED …...I hereby certify that I am authorized, on behalf of the herein named Corporation, Partnership, or Limited Liability Company, to change the

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Page 1: CORPORATION, PARTNERSHIP, OR LIMITED …...I hereby certify that I am authorized, on behalf of the herein named Corporation, Partnership, or Limited Liability Company, to change the

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