NRBA Member Application

- Page One -
 

If you have not done so already:
Please read the NRBA Code of Ethics and NRBA Guidelines ,
prior to filling out this form.

Please read through the application and have the proper information before filling it out.
All information submitted will be verified!
Note:  Please include area codes in your phone numbers.
 
** Required Entries
Personal and Company Information
**First Name   **Last Name    
     
**Home Phone   **Company    
       
**Home Address   **Company Address   **Business Phone   Extension
     
**Home City   **Company City   Pager Number
   
**Company County Cell Number
**Home State
(two letter abbrev.)		   **Company State (two letter abbrev.)   Fax Number
   
**Home Zip   **Company Zip   **E-mail Address
   
**Password Requested:
(6-10 Characters)		 Web Site Address
(if any)
(include complete URL)		  
 
**Verify Password:
(Type it in again.)		    
   
 
Licensing Information
**Owner/Broker **Type of RE License **State of Issue
(two letter abbrev.)
Yes No
**Complaints Pending? **RE License Number **License Expiration Date
Yes No
 
Realtor Board or MLS Affiliation
**RealtorBoard/MLS **Contact Name **Contact Phone
RealtorBoard/MLS Contact Name Contact Phone
RealtorBoard/MLS Contact Name Contact Phone
 
Errors & Omissions Insurance
Are you self insured?  Yes  No
**Company **Policy Number
**Agent **Minimum 500K/1000K?
Yes No
**Agent Phone **Effective Date
**Agent Fax **Claims Pending?
Yes No
 
 References
List financial institutions or corporate clients
for whom you have listed and sold properties for.

A reference request will be sent to those you list below.
Enter Contact Name, Company, Contact Phone, Contact Fax Number in each reference field. 
At least one complete reference is required on this form.

**Person's Name **Company **Phone **Fax
Person's Name Company Phone Fax
Person's Name Company Phone Fax
Person's Name Company Phone Fax
Person's Name Company Phone Fax