ADDRESS CHANGE FORM
ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
Division of Professional Regulation/Real Estate Professions Section
320 West Washington Street
Springfield, Illinois 62786
Real Estate Licensing 217/782-3414
LICENSEE PREVIOUS INFORMATION: |
LICENSE NO. ____________________ |
*NAME _____________________________________________ |
SOC. SEC NO.____________________ |
ADDRESS _______________________________________________________________________________________
CITY, COUNTY, STATE, ZIP CODE _________________________________________________________________
TELEPHONE # ( _ _ _ ) _ _ _ - _ _ _ _ EMAIL ADDRESS________________________________
LICENSEE’S NEW ADDRESS:
MAILING ADDRESS ______________________________________________________________________________
(MUST BE A STREET ADDRESS, P.O. BOXES ARE NOT ACCEPTABLE)
CITY, STATE, ZIP CODE __________________________________________________________________________
TELEPHONE # ( _ _ _ ) _ _ _ - _ _ _ _ |
|
FAX # ( _ _ _ ) _ _ _ - _ _ _ _ |
EMAIL ADDRESS ___________________________ |
SIGNATURE _________________________________________ |
DATE __________________________ |
If you have any questions, please contact our office at 217/782-3414.
*If you need to change your name, please send documentary proof to the address below (i.e., certified or photocopy of a marriage certificate, divorce decree, or court order.)
Return Original To:
Illinois Department of Financial and Professional Regulation
Division of Professional Regulation/Real Estate Professions Section
320 West Washington Street
Springfield, Illinois 62786
Fax: 217-782-3390
320WEST WASHINGTON STREET •SPRINGFIELD, ILLINOIS •62786 •PHONE: 217-785-9300 •FAX: 217-782-3390 •TDD: 217-524-6644 http://www.idfpr.com
IL 505- 0675 (Rev 4/09)
