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Local Agent Removal Request Form

  1. Local Agent Removal Request Form

  2. You are required to submit this form within 7 business days if:

    (please select one)

  3. Designated Agent to be removed:

  4. Agent to be removed

  5. Legal Owner(s) Name:

    *If property is held in Trust, attach names of all beneficial interest holders pursuant to requirements of State Statutes.*

  6. Legal Owner(s)

  7. New Agent Name:

  8. New Agent

  9. P O BOX is not acceptable

  10. First and Last Name

  11. I, the undersigned, hereby certify that:*

  12. Owner's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  13. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  14. Leave This Blank:

  15. This field is not part of the form submission.