NEW CUSTOMER APPLICATION
(* =
required field) |
Are
you a repeat customer? |
Agent Name:*
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SS#:*
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Agent Birthdate:* (ie. 10/02/1952)
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Email Address:*
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Home Phone:*
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Home Fax:
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Mobile Phone:*
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Home Address:*
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City:*
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State:*
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ZIP:*
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I am the:
Listing Agent
Listing Broker
Buyer's Agent
Buyer's Broker
My Home is :
Owned
Leased |
Company Name:*
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Broker/Auth. Rep.:*
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Years with Present Company:*
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Company Phone:*
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Company Fax:*
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Year Licensed:*
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Company Address:*
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City:*
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State:*
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ZIP:*
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Contact Person for Commission Accounting:*
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Contact Person's Phone Number:*
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Contact Person's Email Address:
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Company Website:
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Bank (Personal):*
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If name on account is different than
agent's, please list:
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Account #:*
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Routing #:*
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Property Address:*
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City:*
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State:*
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ZIP:*
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Seller:*
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Purchaser:*
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Is Buyer investor?
Yes
No |
Earnest
Money Amount:*
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Appraisal?:
Not Ordered
Ordered
Completed
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If completed, enter amount of appraisal:
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Settlement Agent (Title Co.):*
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Settlement Rep. (Closer):*
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File Number:
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Settlement Rep Phone:*
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Settlement Rep Fax:*
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Settlement Agent Address:*
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City:*
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State:*
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ZIP:*
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Lender:*
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Loan Officer:*
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If Cash deal, please type 'CASH' in Lender Box. |
Lender Phone :
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Lender Fax:
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Lender Email Address:
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Lender Address:
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City:
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State:
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ZIP:
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Amount Financed:
100%
95%
90%
85% or less
Cash
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Type of Financing:
Conventional
FHA/Government
Owner Carried
Cash
Other |
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Contract Execution Date:
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Option Period Expiration Date:
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Closing Date:*
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Closing Time:
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Final Contract Price:
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Describe any Non-Financing Contingencies in Detail:
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New Construction:
Yes
No
If 'Yes':
Builder Contact:
Builder Phone:
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Receivable Amount:
(Agent's share of commission)
After ALL expenses & deductions, NET amount due to you |
Do you want to sell your entire Receivable, or just a part of it:
All
Part
If Part, enter amount you would like to receive:
(Commission Express will do the calculations to ensure that you receive this exact amount)
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Contracts Currently Pending:
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Closings in Past 12
Months:
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Current Number of Listings:
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Last
Year's Total Income:
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Please send my documents via:
Fax to office
Fax to home
Email
Call me first |
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If this is your first advance with Commission Express, please tell us
how you heard about us (and we like to say thanks for referrals, so if it's a person please tell us their name):
Here's where you can tell us anything special:
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Certification:
I certify under penalty of perjury and of obtaining money under false pretenses that the information provided in this Application is true and correct as of today's date and acknowledge my understanding that any intentional or negligent misrepresentations of the information contained in this application may result in civil liability and/or criminal penalties and liability for monetary damages to Commission Express, its agents, successors, and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I have made on this application. I am at least 18 years of age and a United States citizen. I authorize Commission Express to review my credit history and any other information in order to approve or decline my application, service my account, and manage its relationship with me. I authorize Commission Express to share with others, to the extent permitted by law, such information and its credit experience with me. I consent to and authorize Commission Express to monitor and/or record any of my phone conversations with any of their representatives.
I acknowledge the above certification |
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Remember me as a return customer on future visits! |
| Information submitted is never sold to any third parties. |
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