Complete this form by typing your information in the provided areas.
Please Print and fax it to us at 913-677-6358 (in Kansas City) or 636-405-1585 (in St. Louis)
Agent Name
  		Social Security Number
- - 		Agent License #
& State
Home Phone
- - 		Mobile / Pager Number
- - 		Work Phone
- -
Sales for 2004:
 Sales for 2003:
 Sales for 2002:
Adjusted Gross Income from Most Recent Tax Return:
 for year:
Home Address
 City
 Years at This Address:
 State
 Zip
Nr. of Current Listings
 		Nr. of Pending Contracts
 		Previous Year Commissions
Email Address
Brokerage Name/Contact Person
 		Years at Brokerage
 Brokerage Website
Broker Address
 City
 State
 Zip
Sale Transaction Information
Buyer Name
 Seller Name
Property Location
 City
 State
 Zip
Purchase Price
 Commission Due to Agent
 Contract Date
 Est. Closing Date
Title Company
 File Number MLS#
Closer Name
 Phone Number
- -

Along with this completed Application, please submit the following documentation to Commission Funding:
  1. Copy of subject Real Estate Sales Contract and all Amendments and Addendums
  2. Copy of MLS listing showing property as "Pending Contract", "Under Contract", or similar
  3. Pre-approval letter from Lender
  4. A copy of your valid driver's license.

By signing below, the Agent described above hereby certifies that the information contained herein is true and accurate. Agent authorizes Commission Funding to confirm the accuracy of any information contained herein with any third party. In addition, Agent authorizes Commission Funding to perform, or cause to be performed, credit checks or similar verification of the credit worthiness of Agent.

Agent Signature: _____________________________________________________ Date :______________________