Use the online form below to start the application process and GET PAID!
You can also download this form and fax to 866-531-F3A2S7T8 by clicking here.
Adobe Acrobat Reader is required for downloadable application.
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Agent Name:
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SS#:
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Email Address:
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Home Phone:
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Home Fax:
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Mobile Phone:
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Home Address:
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City:
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State:
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ZIP:
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Date of Birth:
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DRE#:
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| I am the:
Listing Agent
Selling Agent My Home is :
Owned
Leased |
Company Name:
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Broker/Auth. Rep.:
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Years with Present Company:
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Company Phone:
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Company Fax:
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Year Licensed:
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Company Address:
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City:
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State:
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ZIP:
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Commission Accounting Contact:
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Contact Phone:
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Contact Email:
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Bank (Personal):
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Account #:
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Property Address:
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City:
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State:
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ZIP:
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Seller:
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Purchaser:
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Settlement Agent :
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Settlement Rep.:
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Settlement Rep Email :
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Escrow Number :
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Settlement Rep Phone:
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Settlement Rep Fax:
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Settlement Company Address:
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City:
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State:
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ZIP:
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Lender:
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Loan Officer :
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Lender Phone :
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Lender Fax :
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Lender Address:
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City:
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State:
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ZIP:
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Final Contract Price :
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Ratification Date :
Date of final contract acceptance |
Close or Escrow Date :
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Cash Deposit:
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Cash Down:
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| New Construction :
Yes
NO |
Receivable Amount:
(Agent's share of commission)
After ALL expenses & deductions, NET amount due to you |
Do you want to sell your entire Receivable, or just a part of it:
All
Part
If Part, enter amount you would like to sell:
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Settlements
Pending:
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Closed Last 12
Months:
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Number of Listings
Current:
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Last
Year's Total Income:
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How did you hear about us?
Along with the completed application, we require the following documents:
- MLS Listing
- Copy of Purchase/Sales Contract (+ All Counters/Addendums)
- Proof of Escrow
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- Receipt of Deposit
- Buyer's Loan Pre-Approval Letter
- Copy of Driver's License (for a first time application only).
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Please fax these documents to 866-531-F3A2S7T8 or e-mail them to Commission Express. We will contact you upon
receipt of all documents.
Certification:
I certify under penalty of perjury and of obtaining money under false pretenses that the information provided in this Application is true and correct as of today's date and acknowledge my understanding that any intentional or negligent misrepresentations of the information contained in this application may result in civil liability and/or criminal penalties and liability for monetary damages to Commission Express, it's agents, successors, and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I have made on this application. I authorize Commission Express to review my credit history and any other information in order to approve or decline my application, service my account, and manage its relationship with me. I authorize Commission Express to share with others, to the extent permitted by law, such information and its credit experience with me.
I acknowledge the above certification |
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| Information submitted is private, never sold or shared to any third party. |
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