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1.
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Contact Name*
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Title*
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E-Mail
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Work Phone*
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Fax
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Cell
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Address*
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City*
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State*
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Zip Code*
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2.
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Form of business entity*
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Name of entity*
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Prof. Designations (Ex. GRI/CRS)
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DBAs (list all)
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3. Principals
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Owner*
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Licensed date*
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Lic #*
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Broker
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Licensed date
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Lic #
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4.
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# of Brokers*
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# of Agents*
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# of Loan Officers*
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# of Clerical/Unlicensed*
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5. Are you controlled, owned by, or associated with, or
do you control or own any other business?*
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If yes, please describe*
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6. Do you or any principals, partners, brokers, or agents of the applicant participate in
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Real Estate Development/Construction*
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% (of total business)*
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Group Investments/Syndications*
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% (of total business)*
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7.Has any policy or application for EandO insurance on behalf of the firm
or any of its brokers, owners, agents, or of its predecessors ever been declined,
cancelled or non-renewed in the last 5 years?*
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