| * Applicant's Name |
(*By typing my name, I intend this to be my electric
signature and consent as requested by this form) |
| * Email Address (aol, msn, and hotmail are not acceptable) Try Gmail here. |
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| * License Type |
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| * Home Address |
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| * City |
* Zip |
| * Office Name |
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| * Office Address |
* Zip |
* Contact Phone (Will
be on your listings) |
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| * Office Phone |
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| Home Fax |
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| Cell Phone |
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| I herby submit the following information for NSBAR consideration: |
Name as Shown on
License |
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Name to Appear on
Roster |
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| * Birthdate MM/DD/YYYY |
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| Place of Birth |
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| Nickname |
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| *License Number |
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Name of Business if
Sole Owner |
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| Business Address |
Zip |
| Website Address |
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| Membership Certification |
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Do you hold or have you
held, a real estate license
in any other state? |
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If Yes, please specify
state and license number |
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Has your real estate license
in this or any other state ever
been suspended or revoked? |
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If Yes, please specify the
place(s) and date(s) of such
action, and detail the
circumstances relating thereto. |
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Are there now any pending or unresolved compliants, or have there been, within the past 3 years, any complaints against you or the firm with which you have been
associated, before any state real estate regulatory agency or any other agency or government? |
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| If yes, please specify the substance of each complaint in each state, the agency before which complaint was made, and the current status or resolution of such complaint: |
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| Have you ever been convicted of a felony? |
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If so, give the details, including state
and court of conviction: |
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Are you currently a member of another board or association which is affiliated with the NATIONAL ASSOCIATION OF REALTORS®
or have you held membership in another board or association within the past three (3) years? |
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If "yes," list each board and association where membership was held, type of membership held,
and approximate dates of membership. |
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| * Please Select Dues Type |
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This section must be completed by applicants for REALTOR® Membership, whether primary or secondary, who are principals, partners, corporate officers, or branch office managers (i.e. individuals in positions of management control on behalf of individuals who are not physically present and engaged in the real estate profession).
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| State the names and titles of all other principals, partners, or corporate officers of your firm. |
| Name: |
Title: |
| Name: |
Title: |
| Name: |
Title: |
| List the names and addresses of all branch offices or other real estate firms in which you are a principal, partner, or corporate officer: |
| Name: |
Address: |
| Name: |
Address: |
| Name: |
Address: |
| Tax ID Number |
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| Type of Business |
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| Position with Firm |
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| This section is to be filled out by all membership classifications (information is not used to determine membership approval) |
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| Are you a member of an institute, society, or council affiliated with the National Association of Realtors? |
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| If yes, please indicate name of affiliation |
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| List any professional designations you hold |
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| Ethnic/National origin |
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| Languages spoken |
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| Highest level of education completed |
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| First entered the real estate business |
City State
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| Have you been engaged continuously in the real estate business since then? |
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| If not, during what years were you active in real estate |
to |
| In what phase of real estate do you specialize |
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| In what other businesses have you been engaged |
from to city from to city from to city |
| Are you now employed by or engaged in any other busniess or profession? |
Explain: |
| First licensed in the State of Illinois |
and continuously since |
| Established office in present location on |
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| Last previous location |
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| Resident here since |
Year: |
| Previous residence |
City or County: State: |
| Select the names of board committees on which you would be interested in serving |
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| All Membership classifications, please Note: |
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