Freedom of Choice Realty, Inc.

DBPR RE-2050-1--Request for Change of Status
REV 06/01

STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL
REGULATION

CHECK ACTION REQUESTED

TRANSACTION TYPE:

Become Active - no charge
Become Inactive (Brokers only) - no charge
Add/Delete Trade Name - no charge
Become Sole Proprietor - no charge
Change Broker/Owner Employer - no charge
Terminate Employee - no charge
Add/Delete PA-$30.00 fee required - see F.S. 475.161
Request for Multiple License - $95.00
Renew License
Qualifying Broker (CQ package required)
Owner/Developer (Forms 2050 & 0080 required)

SALESPERSON INFORMATION
License Number	Licensee Name
Contact Information (telephone number or E-Mail address)

BROKER OR CORPORATION INFORMATION
Broker License Number BK#251820	Organization License Number CQ#213882
Broker/Owner Name Harold J. Bockhold
Organization Name FREEDOM OF CHOICE REALTY INC
Trader Name (if applicable) N/A	Contact Info. (telephone number or E-Mail address) FCR1980@FCR25.COM
Are you now or with the insurance of this license, an officer, director, member, or partner of any corporation, partnership, or L.L.C. which acts as a broker? Yes No
If yes, please list name of entity FREEDOM OF CHOICE REALTY, INC

ATTEST STATEMENT
REQUIRES SIGNATURE OF EMPLOYING BROKER
(EXPECT FOR ADD/DELETE PA-WHICH MAY BE SIGNED BY THE LICENSEE)

I affirm that I have provided the above information completely and truthfully to the best of my knowledge:

Broker/Owner Sign Here :______________________________Date:_________
***************************BK Signature not req. for Assoc. inactive status or add/delete PA - LLC

Print Broker/Owner Name :____Harold J Bockhold - Broker___Date:_________

Associate Sign Here:__________________________________Date:_________
*********************All Associate requested changes require signature

* This is a facsimile of a downloaded form. Send this form to your new agency