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Agent Release Form
Fill out the agent's name and information below
Agent's Name
*
First Name
*
Last Name
*
Agent's Current Email Address
*
Agent's License Number
*
Name of Person Filling Out This Form
*
First Name
*
Last Name
*
Email of the person filling out this form
*
Name of Firm Conducting Release
*
Choose only one
*
Transfer this agent into another firm
Inactivate the agent license returned to DPOR
Name of the firm agent is transferring to
Revision date: 2/6/24
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