Request to Terminate Your Affiliation with a Firm or Sole Proprietorship

Effective Date of Change*

Your First Name*

Your Middle Name

Your Last Name*

Your License Number*

Your Home Physical Address*

Your Home Physical County*

Your Home Physical City*

Your Home Physical State* PLEASE SELECT ALABAMA ALASKA ARIZONA ARKANSAS AMERICAN SAMOA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLOMBIA DELAWARE FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING OUTSIDE US

9-Digit Zipcode Lookup*

Your Home Mailing Address

Home Mailing County

Home Mailing City

Home Mailing State PLEASE SELECT ALABAMA ALASKA ARIZONA ARKANSAS AMERICAN SAMOA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLOMBIA DELAWARE FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING OUTSIDE US

9-Digit Zipcode Lookup

Is this a new address?* PLEASE SELECT Yes No

Licensee's Public Phone

Licensee's Private Phone*

Licensee's Public Email

Licensee's Private Email*

PLEASE SELECT Yes No

Firm Name*

PLEASE SELECT Yes No

Firm's Office Physical Address*

Office Physical City*

Office Physical State* PLEASE SELECT ALABAMA ALASKA ARIZONA ARKANSAS AMERICAN SAMOA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLOMBIA DELAWARE FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING OUTSIDE US

9-Digit Zipcode Lookup*

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 Request for BIC Eligible Status and-or Broker-In-Charge Designation (REC 2.25) 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.

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Date Signed

4/18/2024