KW/UHG Referral Form
Would you like us to find a referral partner for you?
*
Yes
No- Agent already selected OR this is an incoming referral I need an agreement for.
Your Name
*
First Name
Last Name
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email
example@example.com
Referring/Sending Office Information
Name
*
i.e. David Girard
Firm Name
i.e. Keller Williams Realty Portland Central
Address
i.e. 919 NE 19th Ave, Suite 100
City/State/Zip
i.e. Portland, OR 97232
Phone #
Firm Tax ID
Efax/Fax #
Email
*
Receiving Office/Agent Information
Name
*
Firm Name
Address
City/State/Zip
Phone
Firm Tax ID
Efax/Fax #
Email
*
Prospect Information
Prospect Type
*
Buyer
Seller
Both/Dual
Name
*
Mailing Address
Listing Address
City where Referral Agent is needed
*
State where Referral Agent is needed
*
Mobile Phone
Email
Please add notes on the area/county/city that you need your lead to go to;
Notes/Information
Fee Type
*
Please Select
%
$
Fee Amount (Do not enter % or $)
*
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Complete
If you have your Market Center's W-9, please upload it here:
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