Free 46591.pdf - Indiana

FOR OFFICE USE ONLY

APPLICATION FOR REAL ESTATE LICENSE AS A LIMITED LIABILITY COMPANY
State Form 46591 (4-94) Approved by State Board of Accounts ,1994

License number

Check digit

Date granted

County code number

Date license mailed

Control number

INSTRUCTIONS: 1. For branch office registration, please request Branch Office Registration Form(s). 2. Attach copy of filing certificate from Secretary of State. 3. Mail fifty dollar ($50.00) License Fee to: Indiana Professional Licensing Agency 302 W. Washington St., Rm. E034 Indianapolis, IN 46204

This agency is requesting your federal I. D. number under IC 4-1-8-1. COMPANY INFORMATION
Name of limited liability company Check one Member Managed County Manager Managed Federal I.D. number

Address (Number and street, or rural route, city, state, Zip code)

LICENSE NUMBER

NAME(S) OF MEMBERS OR MANAGERS

CHECK ONE Member Manager Member Manager Member Manager CHECK ONE Member Manager CHECK ONLY ONE Salesperson Broker Salesperson Broker Salesperson Broker Salesperson Broker Salesperson Broker

RESIDENTIAL ADDRESS

LICENSE NUMBER

NAME OF PRINCIPAL BROKER

RESIDENTIAL ADDRESS

LICENSE NUMBER

NAME(S) OF SALESPERSONS AND BROKERS

RESIDENTIAL ADDRESS

Signature of Member or Manager

Date

Telephone number

(

)