Future RExBuy® Licensee's, please complete the following information.  Upon receipt of this form, we will send you the Licensee agreement for your review and acceptance.

Name: 
Address: 
City:   State:   Zip Code: 
Office Phone:   Home Phone:    FAX: 
E-mail: 
Home Page or URL: 
Present Company Name: 
Social Security No.:   Federal Tax ID No.: 
Are you presently a Real Estate Broker?   Yes or No.
If Yes, what is your Real Estate License Number: 
How long have you been a Real Estate Broker?  Years.
Are you a member of your local Board of Realtors?   Yes or No.
Are you in good standing with your States Dept. of Real Estate?   Yes or No.
How many Agents do you have using your license? 

What name would you consider for your firm?  Give us three choices, most desirable first.
Example:
                                                 Charlie Jones          -OR-              Fresno Properties
"  " RExBuy® "  "
"  " RExBuy® "  "
"  " RExBuy® "  "

Your 1st choice should be selected.  We try not to have any duplications within your State.