MLS Only Agent Application | Royal Palm Coast Realtor Association®

Designated Broker Name:*

Broker License Number:*

Broker NRDS/M1 number:*

Primary Broker's Membership held at:*

Brokerage Name:*

Brokerage License Number:*

Office Address:*

Click the checkbox to agree to the following: By typing my name below, I understand that this serves as my electronic signature and confirms my agreement to this application.

Broker Signature:*

Date:*

Phone Number:*

AGENT INFORMATION

Name (1):

License Number (1):

M1/NRDS ID Number (1):

E-Mail Address (1):

Contact Phone Number (1):

Agent's Primary Membership held at:

Payment to be made by:*

Click the checkbox to agree to the following: I agree that, if accepted for Membership in the Association, I shall pay the fees and dues as from time to time established. By signing below, I understand that dues are not refundable. If paid via credit card, I authorize my card ending in the last 4 digits listed below to be used for a one-time payment.*

Last 4 digits of credit card*
You will be asked to provide this full credit card number at the time of application processing. Please make sure it is available for use when ready to make payment for membership. Charges may appear on your statement as REALTOR ASSN/CHICAGO IL.

AGENT 2

Name (2):

License Number (2):

M1/NRDS ID Number (2):

Contact Phone Number (2):

E-Mail Address (2):

Agent's Primary Membership held at:

Payment to be made by:*

Click the checkbox to agree to the following: I agree that, if accepted for Membership in the Association, I shall pay the fees and dues as from time to time established. By signing below, I understand that dues are not refundable. If paid via credit card, I authorize my card ending in the last 4 digits listed below to be used for a one-time payment.*

Last 4 digits of credit card*
You will be asked to provide this full credit card number at the time of application processing. Please make sure it is available for use when ready to make payment for membership. Charges may appear on your statement as REALTOR ASSN/CHICAGO IL.

Please enter the email that you would like a copy of this application sent to: