Firm Name

Representative Name

Social Security #

Address

City State Zip

Phone Fax

E-mail

May NVAR include your e-mail address with your information listed on nvar.com?
Yes No

Web site

Type of Business

Affiliate Type Primary Affiliate ($250 per person) Secondary Affiliate ($150 per person)

Payment Type MC Visa AmEx Discover

Account # Exp Date Mo 01 02 03 04 05 06 07 08 09 10 11 12 Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

By submitting this application, I understand and agree to pay the established dues allocations and fees which are non-refundable. I agree that my act of paying shall evidence my initial and continuing commitment to abide by the Code of Ethics, Constitution, Bylaws, Rules & Regulations, and the duty to arbitrate, all as from time to time amended.

I understand that I may request membership on certain committees and vote on committee matters, but shall not have the right to vote on Board matters or to hold elective office or use the term REALTOR®. And, consistent with Artilce IV, Section C of the NVAR bylaws; I certify that as an applicant for Affiliate Membership, I and my firm are not engaged in the practice of real estate brokerage.