Form Re 620 004A – Fill Out and Use This PDF

Real Estate License Transfer,

Name Change or Reactivation Application

You can use this form to change your name, transfer or reactivate your license. If you are applying for your first broker or managing broker license or reinstating your license, use form RE-620-004, Real Estate License Application. Send this completed form and any required documents to:

Real Estate Licensing

Department of Licensing

PO Box 9021

Olympia, WA 98507

(360) 664-6500 or (360) 664-6488

To transfer your license:

Complete this form and return your current license showing the office you are leaving.

To change your name:

Complete with this form and enclose a brief letter stating what your name is being changed to and from.

Check all that apply:

Transfer

Name change

Reactivation

Applicant information – Incomplete applications will not be processed.

Answer the following

If you answer “Yes” to questions 1-5, attach a letter of explanation. Include the charge, date of conviction, civil judgment or order, county jurisdiction, state, and disposition of charges.

1.With the exception of motor vehicle violations, have you been convicted of a gross misdemeanor or felony, in this or any other state, by the federal government or by any other jurisdiction

within the past ten years?

Yes

No

2.Is there a criminal complaint, accusation, or information presently pending against you or are you currently under indictment, in this or any other state, by the federal government or by any

other jurisdiction?

Yes

No

3.Has any professional or occupational license, certification, or permit held by you been fined, suspended, revoked, refused, or denied, in this or any other state, by the federal government

or by any other jurisdiction in the past ten years?

Yes

No

4.Have you ever had a civil court order, verdict, or judgment entered against you in any court of competent jurisdiction, in this or any other state, by the federal government or by any other

jurisdiction in the past ten years?			. . . . . . . . . . . . . . . . . . . . . . . .	. . . . . . . Yes	No
5. Are you currently required to register as a sex offender in this state or any other state?				. . . . . . . Yes	No
If yes, in which state		and county

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

		X
Date and place signed		Applicant signature

NOTICE: The Department of Licensing may enter your real estate firm’s licensed office location at reasonable times to inspect the records that you are required to keep by the statutes and rules that govern the license for which you are applying. It is your responsibility as a licensee to cooperate with an audit or an investigation by providing DOL with the requested documents and a written explanation of the matter contained in a complaint upon the Department’s request.

RE-620-004A (R/1/12)WRA Page 1 of 2

Employing irm information

TYPE OR PRINT Firm name (where applicant will be licensed)	Firm license number
Mailing address	(Area code) Telephone number
City	State	ZIP code
Physical address (if different)
City	State	ZIP code
TYPE OR PRINT Designated broker name as it appears on your license	License number
TYPE OR PRINT Branch manager name as it appears on your license	License number

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

		X
Date and place signed		Designated broker/ Branch manager signature*

*Submit a copy of the delegation authority if not signed by the designated broker or branch manager.

Once iled, this application is a public record and is subject to public disclosure.

RCW 18.85.191; 18.85.361(6); 26.23.150; 42.56.