Real Estate License Certificate Request Form

Real Estate License Certificate Request Form
Use this form to request a real estate license certificate or related certificate document. Provide accurate contact and request details so the request can be processed.
Applicant Information
Full Name
First NameMiddle NameLast Name
Business/Company Name
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
City
State/Province
Postal Code
License Certificate Request Details
Request Type
Other
License Holder Name
First NameMiddle NameLast Name
License Type
License Number
Issuing State/Region
Certificate Issue Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Request
Reference / Case Number
Delivery and Processing Preferences
Preferred Certificate Format
Delivery Method
Preferred Mailing Address (if different)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Processing Speed
Special Instructions for Delivery or Handling
Should be Empty: