LICENSE VERIFICATION
Ary you a Licensed Real Estate Agent? Yes No If yes, what State(s) / Country are you licensed in?

VERIFICATION OF YOUR ROLE - CHOOSE ONE

1. Principal Owner / Seller / Developer You are the Owner / Developer / Seller and not exclusively working with only one agent. If licensed, you will act as Principal Seller only. 2. Principal Buyer / Investor You are the Buyer / Investor and not exclusively working with only one agent. If licensed, you will act as a Principal Buyer only. 3. Seller's Direct Agent You are a licensed listing agent or agent who has full control/contact with the seller/owner directly and not through any other agent/finder expecting a commission. here if you are a Seller's Direct Agent and use this form. Principals Sellers, please continue down this form. 4. Buyer's Direct Agent You are a licensed agent in direct contact with the actual buyer/investor and not through any other agent/finder expecting a commission. here if you are a Buyer's Direct Agent and use this form. Principals Buyers, please continue down this form. 5. Other (Explain)

CONTACT INFORMATION

Your Valid Email Address (Required) Name & Title Company Mailing Address City, County County State, Zip Code Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Puerto Rico Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington (state) Washington D.C. West Virginia Wisconsin Wyoming          Zip Code Office Phone Ext. Cellular / Mobile Phone Pager Number Home Phone Fax Number Your Home Page (if any)