PARTICIPANT/SUBSCRIBER APPLICATION FORM

APPLICANT INFORMATION

DRE/APPRAISER LICENSE NO*:

LICENSE EXP. DATE*:

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LICENSEE LEGAL NAME :

Prefix

First*

Middle

Last*

Suffix

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LISTING/INTERNET NAME :

First

Middle

Last

Public name for display on Listings or Internet

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APPLYING AS (Select One)*:
Agent Subscriber Designated Participant Manager Appraiser Subscriber Appraiser Participant 

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LICENSE TYPE (Select One)*:
Agent Broker Officer Appraiser Agent  Appraiser Broker 

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CONTACT INFORMATION :

Private email* For MLS correspondence	Public email* For display on Listings or Internet
Agent's Web Address:	Listing/Internet Phone Public phone number for display on Listings or Internet

Home Phone:	Cell Phone:
Fax Number:	Work Phone*:	EXT:

PREFERRED PHONE FOR MESSAGES FROM MLS (Select One)*:
Work Home Cell Office 

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HOME ADDRESS :

Street

City

State

Zip Code

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BILLING ADDRESS :

Street

City

State

Zip Code

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SECURITY QUESTION*: City of Birth

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REFERRING ASSOCIATION/SERVICE CENTER

Select one *:
Santa Clara County AOR Silicon Valley AR San Mateo County AR Monterey County AR Out of Area Santa Cruz County AOR San Benito County AOR Pajaro Valley AOR Central Valley AR MLS Only 

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OFFICE INFORMATION

OFFICE NAME*:	BROKER CODE:
BROKER’S NAME :	BROKER’S DRE #*: FIND BROKER DRE#

PHYSICAL ADDRESS:

Street*

City*

State*

Zip Code*

County*

MAILING ADDRESS:

Street (PO Box)

City

State

Zip Code

OFFICE PHONE*:	OFFICE FAX:
CORPORATION NAME:	CORP. WEB ADDRESS:

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MLS INITIATION FEE (SELECT ONE SUBSCRIPTION TYPE)*:

 PARTICIPANT (BROKER) - $300 SUBSCRIBER (AGENT) - $200

MLS ACCESS FEES (SELECT ONE PAYMENT PERIOD)*:

 ANNUAL ($54 X 12 MONTHS) - $648 SEMI-ANNUAL ($60 X 6 MONTHS) - $360 QUARTERLY ($66 X 3 MONTHS) - $198

(PAYMENT INSTRUCTIONS WILL FOLLOW BY EMAIL)

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SIGNATURES

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I certify that the information given on this application is true and correct. I Agree*

I understand that by becoming and remaining a Participant or Subscriber to the MLS I am subject to the MLS Rules and Regulations as they are from time to time amended. I Agree*

I understand that persons other than principals, partners or corporate officers of real estate or appraisal firms must remain employed by or affiliated with a Participant to remain an MLS Subscriber. I Agree*

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Do not sign the application at this time. You will be notified by email when this form is submitted to DocuSign for electronic signature.

If you are applying as an Agent, your broker will also be notified to sign the form. Once signatures are received,
your membership will be processed within 48 hours.

AGENT SUBSCRIBER ACCEPTANCE: ____________________________________________ DATE: ______________________________

BROKER PARTICIPANT ACCEPTANCE: ____________________________________________ DATE: ______________________________

(IF OFFICE MANAGER IS SIGNING ON BROKER’S BEHALF, ENTER MANAGER’S NAME) ____________________________________________

Input this code to submit form: