New Member

Licensee's Contact Information

First Name^*

Last Name^*

Email^*

Address

Street Address^*

City^*

State^*

Zipcode^*

Phone

Mobile Phone^*

Home Phone^*

Fax Number

SSN

Under section 6109 of the Internal Revenue Code, certain recipients of business payments are required to furnish their social security number to the payer who must report such payments to the Internal Revenue Service on Federal Form 1099. As a Referral Associate, you may receive such business payments from time to time and therefore we must have this information on file.

Social Security Number^*

License

Provide your 7 digit license reference number if you have it. Or look up here: https://www-dobi.nj.gov/DOBI_LicSearch/recSearch.jsp

License Reference Number

Is your license currently held by a brokerage?^*

Yes

Affiliation

Former Board/Association Affiliation^*

NJRN Terms

Do you agree to the terms in the NJRN Agreement?^*

By selecting "Yes", I UNDERSTAND AND AGREE TO ALL THE TERMS CONTAINED IN THE NJRN MEMBER AGREEMENT INCLUDING ADDENDUM A WHICH EXPLAINS WHAT REAL ESTATE BROKERAGE ACTIVITIES I CAN AND CANNOT ENGAGE IN AS A REFERRAL AGENT. I ALSO UNDERSTAND THAT WHEN SELLING ANY REAL ESTATE IN WHICH I HAVE AN OWNERSHIP INTEREST OR PURCHASING ANY REAL ESTATE FOR MY OWN PERSONAL PORTFOLIO THAT I AM REQUIRED BY THE NEW JERSEY REAL ESTATE COMMISSION TO INFORM ALL PARTIES TO SUCH A TRANSACTION THAT I HOLD A NEW JERSEY REAL ESTATE LICENSE.

Yes