Broker Information

This form must be completed by the Licensed Broker of Record for the Firm identified below.

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Avaliable associations		Association memberships
Broker’s name*		Broker’s phone number*
Office manager		Broker’s fax number*
Broker’s email (This will be your login ID)* check availability		Username for Real Estate Forum* check availability
Password*		Verify Password*
Broker’s license number*		Firm’s name*
Firm type* Independent non-franchised company Independent franchised company Franchised subsidiary of a national or regional corporation Non-franchised subsidiary of a national or regional corporation		Firm’s license number(s)*
Principal address* City* State* Zip* Select AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict Of ColumbiaDelawareFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming		Firm’s web site(s)
Years of operation*		Number of agents*	Number of offices*
Referred by* No Referral E-mail Invitation Media Advertisement Real Estate Convention Fellow Broker Other