Real Estate Agent/Broker Panel Application Form



This form is to be used by Real Estate Agents and Brokers interested in becoming a CoreLogic® Valuation Solutions vendor. To begin the application process, please complete each section of this online form in its entirety. Once received in our system, your information will be stored in an applicant database and applicants meeting our needs will be contacted when openings arise in their location.


Section 1: Applicant Name, Contact Information & Home Address

indicates required fields


First Name:
Middle Name:
Last Name:
Email Address:
Cell Phone:
Primary Work Phone:

Current Home Address

No P.O. Box Allowed
Street Address:
Address 2:
Zip Code:
City:
State:
County:

Length of Time at Address:
 
Years
If under 1 year, provide prior home street address:

Prior Home Address

Street Address:
Address 2:
Zip Code:
City:
State:
County:

Length of Time at Address:
 
Years


Section 2: Company Name, Contract Information & Business Address



Company Name:
Company Email Address:
Company Work Phone:

Company Address

Street Address:
Address 2:
Zip Code:
City:
State:
County:

Length of Time at Address:
 
Years
Are you the office Broker?

Broker's Name:
Broker's Phone:
How long have you been at this company?
 
Years 
If under 1 year, provide name of prior employer and dates employed by them:
Prior Company Name:
Prior Employment From:
To:



Section 3: Errors & Omissions Insurance Information



Company Name:
Policy #:
Expiration Date:
Individual Claim Amount:
Aggregate Claim Amount:


Section 4: Experience & License Information




Are you a Real Estate Agent?

Are you a Broker?

How long have you been in the real estate profession?
Years
Provide the month and year that you first obtained your real estate license.


Month:
Year:
For every real estate license that you currently hold, provide the following:
State License Number Issued Date Expiration Date License Type  
 
 

 
 

 
 




Section 5: Professional Designations



List all that currently apply:


Section 6: Languages Spoken




List all languages other than English that you are able to speak fluently:


Section 7: Professional References



Provide the names and contact information of three individuals who will serve as references that we can contact to verify your professional experience. One of the references must be a Financial Institution or an Appraisal Management Company, other two may be BPO companies or current clients. By providing their names and contact information, you are authorizing us to contact each individual.
First Name Last Name Relationship Company Name  Phone #  





















Section 8: Product Competency & Production Past 12 Months


Within the grid below, please identify each real estate related product that you have the training and experience to competently perform by entering the total number of each product completed by you over the past 12 months.

Product NameInterior
CMA/BPO
Exterior
CMA/BPO
Property
Condition
Report/Disaster
Inspections
Other
#
Completed
Past
12
Months
 
 
 
 
 
 
 
 



Section 9: Service Territory & MLS Subscription Validation


Enter the requested data for every specific geographic area in which you have the training, experience and data needed to competently complete an appraisal assignment. If you only cover specific zip codes with in a particular county, input each zip code that you specifically cover.
State  County  All Zips Covered?  If no, list the zips you cover  Does the MLS that you suscribe to cover this area?  If no, list the alternate data sources that you use in this area.   

















Thank you for expressing an interest in becoming one of our vendors.

Please click on the submit button only once. If you have submitted a profile and need to make a correction, please call 877-352-4650 opt. 3.

By clicking the submit button, I certify that I have filled out each section honestly and accurately.