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Commissin Express Commission Advance Application

Use the online form below to start the application process and GET PAID!

You can also download this form and fax to (703) 560-5502 by clicking here.
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REPEAT CUSTOMER APPLICATION
WITH INFORMATION UPDATES
(* = required field) 		Are you a new customer or a returning customer without information updates?
Agent Name:*
 SS#:*
Email Address:*
Home Phone:
 		Home Fax:
 Mobile Phone:
Home Address:
 City:
 State:
 ZIP:
I am the: Listing Agent     Selling Agent            My Home is : Owned     Leased
Company Name:
 Broker/Auth. Rep.:
 Years with Present Company:
Company Phone:
Company Fax:
 Year Licensed:
Company Address:
 City:
 State:
 ZIP:
Bank (Personal):
 Account #:
Property Address:*
City:*
State:*
 ZIP:*
Seller:*
Purchaser:*
Settlement Agent:*
Settlement Rep.:
  
Settlement Rep Phone:
 Settlement Rep Fax:
  
Settlement Company Address:*
 City:*
 State:*
 ZIP:*
Lender:*
 Loan Officer:*
Lender Phone:*
Lender Fax:*
  
Lender Address:*
 City:*
 State:*
 ZIP:*
Final Contract Price :*
 Ratification Date:*

Date ALL contingencies except financing have been removed 		Settlement Date:*
New Construction : Yes     NO
Receivable Amount:*

(Agent's share of commission)
After ALL expenses & deductions, NET amount due to you

Do you want to sell your entire Receivable, or just a part of it:
 All            Part

If Part, enter amount you would like to sell:

Cash Deposit:

Cash Down:

Settlements Pending:

Closed Last 12 Months:

Number of Listings Current:

Last Year's Total Income:

Upon receipt of your application we will fax you the following documents: Certification and Notice of Assignment (Acknowledged by or letter from Settlement Agent). You will need to provide MLS Listing Printout (Status: Under Contract/Pending/Sold).

Certification:
I certify under penalty of perjury and of obtaining money under false pretenses that the information provided in this Application is true and correct as of today's date and acknowledge my understanding that any intentional or negligent misrepresentations of the information contained in this application may result in civil liability and/or criminal penalties and liability for monetary damages to Commission Express, it's agents, successors, and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I have made on this application.

I acknowledge the above certification

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Commission Express of Northern Virginia is a member of: Dulles Area Association of REALTORS®, Northern Virginia Association of REALTORS®, Virginia Association of REALTORS®, and National Association of REALTORS®