Realtor Membership Application Form
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1
2FOR OFFICE USE ONLY
Member # ________________________
Office # _____________ MLS Y / N
New / Transfer / Reinstate
Member Type _____________________
NRDS # _________________________
REALTOR
Membership Application
®
Pub List
Orientation
MLS Fee
Membership type: o Agent-REALTOR
o Broker-Designated REALTOR
o Appraiser o Assessor o Ltd. Broker
®
®
o Primary o Secondary o Non-Member Licensee
If applying for Secondary membership, please name your primary association _________________________________________
Previous assoc. membership? If yes, where/when? _________________________________ I have a Supra Key: Yes/No _______
Name as it appears on your real estate, appraiser, assessor or limited broker’s license (VERY IMPORTANT!):
First Name __________________________ Last Name ___________________________ Middle Name _________________
Home Address ________________________________________________________________________________________
City ___________________________________________________ State ___________ ZIP _________________________
Home Phone ____________________________________________ Home Fax ____________________________________
Date of Birth
_______________________________ Cell Phone ____________________________________
(Month/Day/Year)
MN Real Estate License # ___________________________________ Appraiser License # (if applicable) __________________
Preferred Contact Number
___________________________________________ Nickname: ___________________
(required)
Preferred Email Address (required) _________________________________________________________________________
Preferred Mailing Address o Office o Home
Preferred Fax o Home o Office
Are you currently, or have you served, in the U. S. Military? If yes, which branch? _____________________________________
Website http:// ________________________________________________________________________________________
Language(s) Spoken ____________________________________________________________________________________
______________________________________
National Association of REALTORS
®
Institute or Society Designations
(if any)
Broker Office Name _____________________________________________________________________________________
Broker Office Address ____________________________________________________________________________________
City ___________________________________________________ State ____________ ZIP _________________________
Broker Office Phone _______________________________________ Broker Office Fax ________________________________
If you are an office broker—MN Corporate License Number ______________________________________________________
Have you personally or an office where you have been a sole proprietor, general partner, corporate office or branch office manager had
a bankruptcy in the past three years or do you have a pending bankruptcy? o Yes o No
During the past three years, have you had an official sanction involving civil rights laws, real estate license laws or other laws?
o Yes o No If you answer yes to either or both of the above questions, provide written details.
Do you have any outstanding Code of Ethics complaints or unsatisfied ethics or arbitration decisions, unpaid arbitration awards,
association or MLS service? o Yes o No If yes, please explain:
unpaid financial obligations to any REALTOR
®
_____________________________________________________________________________________________________
Your position at firm: ________________________ o Principal o Partner o Corporate Officer o Trustee o Employee o Other
Is your firm incorporated? o Yes o No
Applicants for Membership who are Brokers/Owners of a real estate firm, state name of each Principal, Partner, Corporate
Officer or Trustee of your firm: _____________________________________________________________________________
_____________________________________________________________________________________________________
(Over – complete reverse side )
5750 Lincoln Drive • Minneapolis, MN 55436 • 952.933.9020 phone • 952.933.9021 fax •
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