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Local Agent for Licensed Properties

  1. Local Agent for Licensed Properties - Text

  2. Address of Property

  3. Owner's First & Last Name

  4. Agent's First & Last Name

  5. P.O. Box Not Acceptable

  6. I, the undersigned, hereby certify that:*

    By checking the "I agree" box below, I/we authorize my/our aforementioned agent to act on my/our behalf as my/our registered agent, and assume all of the duties listed above. However, I/we understand that as the legal owner(s) of this property I/we will be responsible for the actions/and or infractions of the agent listed above.

  7. Owner's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  8. Agent's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  9. Leave This Blank:

  10. This field is not part of the form submission.