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Referral Registration Form

All information is required to Register your Client or Customer.  Company/Broker Tax I.D. MUST be submitted no later than 10 days after submission.

ALL REFERRALS MUST BE MADE BY A LICENSED AGENT WORKING FOR A LICENSED BROKER IN ACCORDANCE WITH 54.1 OF THE VIRGINIA CODE!!

AGENT/BROKER INFORMATION

Your First Name  

Your Last Name  

Your Brokerage Firm's Name  

Your Brokerage Firm's Address                    

 

Your Brokerage Firm's Tax I.D.

Your Brokerage Firm's Phone Number --       

                                                     Fax --

Your e-mail Address

Your Web Site

INBOUND REFERRAL INFORMATION

Your Clients Name

Is this a Corporate Relocation Yes  No  

Is your Client aware of the referral   Yes   No

Client Contact Number --   

Client  e-mail

Does your Client have a property to     

Enter the best time to call your Client (ref. time zone please)


4090-B Lafayette Center Dr.
Chantilly, VA 20151

Office: 703-652-5702
Fax: 703-263-2510
E-mail: info@markhastings.net



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