Commercial Broker Membership Application

Name*

First Middle Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Cell Phone*

SMS / Text Messaging Opt in?

Opt in to receive billing and other important information via text messaging. (Standard messaging rates may apply)

Company Name*

Office Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone*

For which State(s) do you currently hold a Real Estate License?*

KS License #*

First Name on KS License*

Middle Name on KS License

Last Name on KS License*

MO License #*

First Name on MO License*

Middle Name on MO License

Last Name on MO License*

Do you hold or have you held a Real Estate License in any other States?

If yes, please list state(s) and license # above

Designations

Area(s) of Specialty

Application Fee of $150 and Annual Membership Fee of $155 is due prior to application processing.*

Price:

Credit Card Number*

Expiration Date:*

For two digit date just use first day of month. i.e. 11/2024 would be 11/1/2024.

CID # / Security Code – (Usually on the back of your debit or credit card.)*

3 or 4 digit code

Credit Card Authorization Signature*

Store CC Information for future payments

Enroll in Auto Pay?*

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Form Type