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Get and Sign Notice Assumed Name Form
LICENSE.
Expiration Date
License Number
Check if changed from mailing address of record.
Name on Broker's License
Mailing Address
State
City
Zip Code
Phone number
e-mail address
Broker's Printed Name*
Broker's Signature*
Date
Delegated Supervisor's Printed Name**
Delegated Supervisor's Signature**
Date
*If Business Entity: printed name and signature of Designated Broker is required.
** Delegated Supervisor under 22 TAC §535.2(e).
LIST EACH ASSUMED BUSINESS NAME (DBA)
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