Broker Application Form

Your info:

Last Name: First Name: Middle:
 
Resident Address: Social:
 		 Home Phone:
Cell Phone: Email: State Licensed:
Date of Birth: License Number: License Type:
Expires: License Issue: Job Title:


Company info:

Company Name: Company Type: Date Formed:
Company Address: TIN: Company License Type:
State Licensed: Principal of Company: Social Security Number:
License No: License Number: Percentage Of Ownership:
Number of Account Executives: Number of Office Staff: Net Worth:


List at least three business references below.

Name of Company 1: Contact 1: Telephone 1:
Name of Company 2: Contact 2: Telephone 2:
Name of Company 3: Contact 3: Telephone 3:
 

Please provide your responses to the following questions.

Do you currently lease or own office space where you will conduct business?:
Do you possess a valid & current business or occupational license where your office is located?:
How long have you worked in the field of mortgage financing?:
Do you have experience brokering or originating commercial loans?:
Do you have a fictitious name registered with the state in which you will conduct business?:
Have you filed documents with the state to form a legal entity under which you will conduct business, such as a corporation, limited partnership, limited liability company, etc.?:
Are there any other owner’s of the business besides those listed on the Branch Broker Application Form?
 If so, please provide their names and the percentage share for all individuals and/or entities that have 10% or more ownership interest in the company. Email it here:
Which states do you currently conduct lending or brokering activities?:
Have you ever had a license suspended or revoked by a licensing entity?
 If so, please attach a written explanation to this application stating when the situation occurred, the license type, the state issued, the circumstances of the disciplinary action and the resolution. Email it here:
Have you ever been required to pay administrative fines or penalties as a result of license violations?:
Have you ever been sued or paid a settlement for business activities conducted by you or your company?
 If so, please attach a written explanation to this application stating when the situation occurred the amount of the settlement or verdict, and the allegations made against you. Email it here:
Are you currently a party to a lawsuit?
 If so, please provide a written explanation stating the whether you are defendant or plaintiff, the nature of the allegations and the probable outcome of the litigation. Email it here:
Have you ever been convicted of or pled no contest to a felony?
 If so, please attach a written explanation to this application explaining when the situation occurred, the nature of the charge(s), the state where the offense occurred, whether you served jail time or probation and an explanation of the circumstances surrounding the situation.
Email it here:
Have you ever filed bankruptcy either personal or business?
 If so, please attach a written explanation to this application stating when the bankruptcy was filed, when discharged or dismissed and the circumstances surrounding the filing.
Email it here:
Have you ever had a broker or correspondent relationship terminated for cause?
 If so, please attach a written explanation stating the reason for termination, the investor or lender that terminated you and the date.
Email it here:

ACKNOWLEDGEMENT

I hereby attest that the statements provided in this Branch Broker Application are true and accurate to the best of my knowledge as evidenced by my signature below

 

  
Signature:
Or Download Broker Application and Fax to 954-847-9953