Greater South Bend-Mishawaka Association of Realtors®, Inc.
1357 Northside Blvd.
South Bend, IN 46615
Phone: (574) 289-6378
Fax: (574) 287-0570
6/07
APPLICATION FOR AFFILIATE MEMBERSHIP
- Name: ______
2. Date of Birth: ______3. Social Security Number:_XXX-XX-______(Month) (Day) (Year) (Last 4 Digits Only)
4. Home Address: ______
(Street) (City) (State) (Zip Code)
5. Home Phone: _(____)______6: Cell Phone:_(____)______
7. Name of Company: ______
8. Service/Product Provided:______
9. Your Office Address: ______
(Street Address)
______
(City) (State) (Zip Code)
Corporate Office Address: ______
(Street Address)
______
(City) (State) (Zip Code)
10. Office Phone: _(____)______Fax Phone:_(____)______
11. E-Mail Address: ______
Mandatory (Required to keep current e-mail address on file at the Association Office)
12. Your Position In The Company: ______
13. Have you ever been a member of this Association? Yes No ; If yes, what years? ______
14. Are you now subject to any bankruptcy or insolvency proceedings? Yes No ; If yes attach an additional
page (numbered “13”) and explain in full.
15. Do you have financial problems which could jeopardize those doing business with you? Yes No ; If yes,
attach an additional page (numbered “14”) and explain in full.
16. Are there any unresolved complaints, charges or actions against you by any civil rights agency, consumer protect-
ion agency, any other agency, board or commission? Yes No ; If yes, attach an additional page (number-
ed “15”) and explain in full.
17. Have you ever been convicted of a felony and/or misdemeanor other than a traffic violation? Yes No ; If
yes attach an additional page (numbered “16”) and explain in full.
18. Are there currently any civil or criminal suits pending against you? Yes No ; If yes, attach an additional
page (numbered “17”) and explain in full.
19. Are you subject to any unpaid judgments? Yes No ; If yes, attach an additional page (numbered “18”) and
explain in full.
(over)
20. Please list three business references.
NameCompanyPhone Number
______
______
______
21. Give the name, firm and phone number of the last three persons for whom you have worked.
NameCompanyPhone Number
______
______
______
I HEREBY APPLY FOR MEMBERSHIP IN THE
GREATER SOUTH BEND-MISHAWAKA ASSOCIATION OF REALTORS®, INC. AND
- Submit a check for $ ______payable to Greater South Bend-Mishawaka Association of Realtors which
will be refunded if I am not elected into membership;
b. Agree to abide by the Bylaws and Rules & Regulations of the above named Association;
c. Consent to the Association’s authorized representatives’ inviting and receiving comments about me from any
member or other person;
d. Agree that any information received in connection with this application shall be conclusively deemed to be
privileged and not form basis of any civil action by me (slander, libel, defamation, fraudulent misrepresentation,
invasions of privacy, etc.);
e. Waive, irrevocably, any and all claims against the Association, its officers, directors and members for failing to
elect me to membership;
f. Certify that the information provided in this application is true and correct;
g. Understand that failure to provide complete and accurate information or any misstatement of fact will be grounds
for termination of my membership should it be granted.
Date: ______Signature: ______