MBM Affiliate Membership Application

Affiliate Membership Application

For non-licensed real estate associated businesses.
I hereby apply for Membership in the *
Membership Type:*

Affiliate MemberAdditional Affiliate
Contact Name*

First NameMiddle NameLast NameSuffix
Nickname
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
M1 #
Office Name*
Firm M1 #
Office Address (Principal place of business)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Website
Cell Phone *
Office Phone*
Office Fax
Type of Business*
ex. Inspection, Pest Control, Lending, Investment
Title*
ex. Lending Officer, Manager, Inspector
Are you a member of an Institute, Society or Council affiliated with the National Association of REALTORS®?*

YesNo
If yes, please indicate the name of the affiliation::
Do you currently hold a real estate or appraisers license?*

YesNo
If yes please enter your license number:

0/7
Please list any professional designations that you currently hold:
Upon acceptance of my affiliate membership, I hereby agree as follows: (1) to pay the prescribed dues for such membership category in accordance with bylaws of the board (2) to comply with and abide by the bylaws as may be attended from time to time by the board, which I hereby acknowledge that I have read and understand; and (3) to comply with and abide by any other rules and regulations adopted by the board of directors as they affect my membership category.

The Applicant hereby agrees to be responsible for the payment of dues and other monetary obligations to the board for membership and any other members of the firm who join as “additional affiliates”; and the provisions of this paragraph are valid, binding and enforceable obligation of the Applicant. I hereby certify that the foregoing information furnished by me is true and correct, and I agree that failure to provide complete and accurate information as requested, or any misstatement of fact, shall be grounds for revocation of my membership if approved by
the board of directors.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: