Agent Form

1

Terms and Conditions* This field is required.

2

What is the closing property address?Please input the full address below

Closing Property Address

3

Agent's Name* This field is required.Please enter your full name below:

Full Name

4

Agent's Email Address* This field is required.Please enter your email address below:

example@example.com

5

Agent's license #* This field is required.Please enter your license number below:

6

Agent's Brokerage Name* This field is required.Please enter your brokerage name below:

7

Are you the Listing Agent or Buyer’s Agent?* This field is required.Please select one

Listing Agent

Buyer's Agent

8

What is the commission percentage or total amount of commission due to YOUR brokerage?Do not include the amount being paid to the buyer's agent

%

$

9

What is the commission percentage or total amount of commission due to the Buyer’s Agent’s brokerage to be paid by the SELLER?

%

$

10

What is the commission percentage or total amount of commission due to YOUR brokerage?Do not Include the amount being paid to the listing agent

%

$

11

Who is paying:* This field is required.Select option:

Amount Paid your brokerage by the SELLER

Amount Paid your brokerage by the BUYER

Amount or percentage paid by both/split

12

Seller and Buyer Amount Split* This field is required.Can be dollar amount or the percentage

Amounts to be paid by Buyer

Amounts to be paid by Seller

13

Transaction fee or Brokerage fee amount to be collected from your client* This field is required.NOTE: If you are paying the fee on behalf of your client from your commission, enter 0 (zero)

Please enter the dollar amount

14

Will you have a Disbursement Authorization from your broker to split the commission and pay you directly at closing?* This field is required.

YESNO

15

Enter address to send brokerage commission check to* This field is required.

Please enter the address

16

Do you want a check or wire for your commission? * This field is required.

Check

Wire

17

Wire Information* This field is required.Please Fill out the requested information below

Bank Name

Routing Number

Account Number

Your Name on The Account

Your Mailing Address

18

How would you like to receive the check?* This field is required.

I will pick up my check

Send it through Mail

19

Please enter the mailing address* This field is required.

mailing address

20

Confirmation* This field is required.