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Real Estate Agent Online Application Form

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Agent Profile

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Mobile Number*

Emergency Contact Person*

Emergency Contact Number*

RE License Number*

Which of the following describes you?*

My Georgia real estate license is "Active"

My Georgia real estate license is "Inactive"

How do you want Realty Hub to pay your real estate commission?*

Paid to My Personal Name

Paid to My Corporation

SSN

We are asking for your SSN in lieu of filling out a W9. If you prefer to fill out the W9, you can download the W9 form at the end of this application process and email it to us.

Corporation Name*

EIN*

Are you working Full Time or Part Time in real estate?*

Full Time

Part Time

Referral Program/Hang My License

Do you hold any Professional Designations? (CCIM, GRE, etc.)*

Yes

No

Please provide details*

Are you engaged in any business enterprise, professional practice or services other than real estate sales?*

Yes

No

Please provide details*

Do you own, manage, or control any other entity, including any subsidiary?*

Yes

No

Please provide details*

a. Do you refer clients to such entity?*

Yes

No

b. Is written disclosure of such ownership, management, or control provided to each client referred?*

Yes

No

Have you been subjected to a felony conviction, license surrender or been subjected to any investigation, license revocation, suspension or other disciplinary action by any licensing board, real estate association, or other regulatory body within the past 5 years?*

Yes

No

Please provide details*

Have you been subjected to any lawsuits and Errors and Omission Insurance Policy claims in the past 5 years?*

Yes

No

Please provide details*

Phone

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