Application for Affiliate Membership

Membership Type

Current Month

First Name

Middle Initial

Last Name

Home Address

City

State

Zip

Phone

Email

Title

Firm Name

Office Address

Office City

Office State

Office Zip

Firm Phone Number

Business Website (for use on CWBR website ads)

Briefly describe your firm’s activities and your duties:

Are you a licensed real estate Broker?

Yes No

Are you a licensed real estate Salesperson?

Yes No

Has a real estate licensing agency ever denied, revoked, suspended or withdrawn your license or that of any partnership or corporation of which you were a member or officer?

Yes No

If yes, give details

Has any legal or administrative action ever been begun against you in which fraud, dishonesty or deceit was alleged?

Yes No

If yes, give details

Are there any unsatisfied judgements of record against you personally or against any firm of which you are or have been a partner or officer?

Yes No

If yes, give details

Have you, or any firm of which you are or have been a partner or officer, been adjudicated a bankrupt or made an assignment for the benefit of creditors within the past six years?

Yes No

If yes, give details

Would you like a Supra Key? ($150 one-time set-up fee and recurring fees apply)

Yes No

Would you like access to the Multiple Listing Service? (additional fees apply)

Yes No

Name

Date

Payment Method

Would you like to donate $20 to WRF - Wisconsin REALTORS® Foundation, Inc

Payment Due

COMPANY INFORMATION