Company Data Form

Reason for Form (check all that apply):
New Firm or Branch Office
Firm name Change
Change in Designated Realtor
Change in Ownership, Officers

Type of Business:
Proprietorship
Partnership
Corporation
Limited Liability Corp.

Corporate NRDS#:
Designated Realtor:
Broker's/Appraiser's License:
Name of Company:
Phone #:
Company Street Adress:
City:
State:
Zip:
Company Mailing Address:
City:
State:
Zip:

Email Address:
Company Web Page:

PLEASE LIST OWNERS/OFFICERS:
(include positions and titles)

Name:
Position:
Licensed in Real Estate?: Yes No
License #
Broker Salesman
Actively Engaged in Real Estate?: Yes No
Home Address (include Street address, city, state and zip):

Phone #:
 

Name:
Position:
Licensed in Real Estate?: Yes No
License #
Broker Salesman
Actively Engaged in Real Estate?: Yes No
Home Address (include Street address, city, state and zip):

Phone #:
 

Name:
Position:
Licensed in Real Estate?: Yes No
License #
Broker Salesman
Actively Engaged in Real Estate?: Yes No
Home Address (include Street address, city, state and zip):

Phone #:

Are you involved in any pending bankruptcy or insolvency proceedings or been adjudged bankrupt within the past three years? Yes No
If "yes", please explain:

I Agree