REALTOR® Inactive Status Form

Please submit this form if you or one of your agents plan to return their license to the state, we kindly ask that this form be completed to process your request.

Fields marked with an * are required.

Agent's First Name *

Agent's Last Name *

Agent's Phone Number *

Agent's Email Address *

Agent's License Number *

Brokerage Name *

Brokerage Address *

Include city, state, and zip code

Requested Effective Date of Inactive Status *

I understand reactivation may require fulfillment of payment of applicable fees *

This form is being filled out by *

Agent requesting inactive status

Broker requesting inactive status

Office Administrator requesting inactive status

I acknowledge this request requires signatures of both broker/office admin & agent to be processed *

In order to process membership inactive status request, I acknowledge that both agent and broker/office admin signatures are required.

Agent Signature *

Broker/ Office Administrator Signature *

Please verify that you have checked the “I'm not a robot” checkbox.