APPLICANT INFORMATION FOR INDEPENDENT AGENT

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Date Available*

Agent #

State License

Yes
No

Desired Location (Counties, State)*

Are you a citizen of the United States?

Yes
No

If no, are you authorized to work in the U.S.?

Yes
No

Have you ever worked for this company?

Yes
No

If so, when?

Have you ever been convicted of a felony?

Yes
No

If yes, explain

EDUCATION

High School

Address

From, To

Did you graduate?

Yes
No

Degree

College

Address

From, To

Did you graduate?

Yes
No

Degree

Other

Address

From, To

Did you graduate?

Yes
No

Degree

REFERENCES

Please list three professional references

Name

First Last

Relationship

Company

Phone

Name

First Last

Relationship

Company

Phone

Name

First Last

Relationship

Company

Phone

PREVIOUS EMPLOYMENT

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From, To

Reason for leaving

May we contact your previous supervisor for reference?

Yes
No

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From, To

Reason for leaving

May we contact your previous supervisor for reference?

Yes
No

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From, To

Reason for leaving

May we contact your previous supervisor for reference?

Yes
No

MILITARY SERVICE

Branch

From, To

Rank at Discharge

Type of Discharge

If other than honorable, explain

ADDITIONAL QUESTIONS

If you have been in contact with a LandProz team member, please put their name below.*

What qualities do you believe make an excellent real estate agent?

How do you utilize the internet and social media? As business, personal or both? Explain.

How will you communicate with Landproz Real Estate LLC regarding your efforts (email, phone, txt, fax)? Explain.

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to self-employment with Landproz Real Estate LLC, I understand that false or misleading information in my application or interview may result in my release.

Electronic Signature*

Date*

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