Application for Designated REALTORS

DUES AND APPLICATION FEES ARE NOT REFUNDABLE

* Name:

Name as you want it to appear in the roster:

* Office Name:

* Office Address:

* Office City:

* Office State:

* Office Zip:

* Office Phone:

Office Fax:

* Home Address:

* Home City:

* Home Zip:

Date of Birth:

Social Security Number:

This field is not required online. You may wait to give your SSN upon visiting LBAR's office.

* Home Phone:

This number will appear on listings & LBAR.com

* Real Estate License number:

* E-mail address:

Web Page address:

Voice mail:

* Cell Phone:

Do you want your cell phone number published in the LBAR Roster:

	Yes
	No

* Have you been or are you currently a member of any other real estate association:

	Yes
	No

If "yes", name the Association, type of membership held, and the time period for which membership has been held.:

If "yes", please enter your NRDS number? (National Realtor Data System number).:

* Are you aware that your services will be suspended if you fail to complete the (15) hours of required orientation classes within 120 days of joining?:

	yes
	no

* I have read the orientation/education requirements.:

The orientation/education requirements are available by visiting http://www.lbar.com/designatedrealtor.htm.

* I have read the Designated REALTOR admission procedures: