Request to Terminate Your Affiliation with a Firm or Sole Proprietorship

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Licensee Details

Firm Details

Signature and Certification

By signing below, you are acknowledging that you are no longer affiliated with the firm referrenced above.

Please Note: Before a Broker-in-Charge is removed, a new properly completed Broker-in-Charge Declaration Form (REC 2.04) should be submitted to the Commission. Otherwise, when a Broker-in-Charge is removed from a firm or sole proprietorship, all licensees affiliated with that Broker-in-Charge will be affected. Provisional brokers will be placed on Inactive Status. “Full” brokers will remain on Active status at their home addresses but will no longer be affiliated with the firm/sole proprietorship.

(Type your name)

Date Signed


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This form is not meant to be printed. If you have already completed the form please use the submit button at the bottom to send the form directly to the Commission.