AGENT REGISTRATION FORM

Transaction Coordinators

AGENT REGISTRATION FORM
If you have not previously used REMERGE Transaction Coordinators, please fill in and submit this form.
You will only have to do this once. This will facilitate future transactions.

If you encounter any difficulties submitting this form contact us at 1-877 473-6374

* required fields
Your Information
Please DO NOT TYPE EVERYTHING IN CAPS!!

*Your Full Name

DRE Number

*Office

Manager/Broker Name

Office Address

City

State

Zip

Office Phone

Office Fax

Home Phone

Home Fax

Web site Address (ie: www.greatrealtor.com)

Cell Phone

* e-mail

Contact Me By

Assistant Name

Assistant Phone

Asssitant Fax

*Preferred Phone:

Preferred Fax:

Prerferred Escrow Company

Preferred Escrow Co Phone

Prerferred Zone Disclosure Company

Preferred Zone Disclosure Co Phone

If your mailing address is different than your office address, please fill the boxes below:

Mailing address

City

State

Zip

GENERAL INSTRUCTIONS FOR YOUR REMERGE TRANSACTION COORDINATOR

Please let us know how you found out about REMERGE Transaction Coordinators
or who referred you to our service. Thank you.

Select Your Own REMERGE TC Agent Password

IMPORTANT: The password you choose MUST BE alphanumeric:
it HAS TO CONTAIN LETTERS AND NUMBERS
and BE AT LEAST 6 CHARACTERS LONG.
For example: Mary56 or Peter51
*