does hereby make application for Affiliate Membership in the New Jersey
Land Title Association (NJLTA) and agrees to comply with all provisions 
of the Association's Constitution, By-Laws and Code of Ethics.

In support of our request, we submit the following information;

Name of person completing application _____________________________________

Signature _________________________________________________________________

Business Address __________________________________________________________

City,State,Zip  _________________________________ County __________________

Telephone ____________________________    Fax _____________________________

Name the authorized officer of your company to whom official
correspondence should be directed


___________________________________________________________________________
      FIRST NAME         MIDDLE INTIAL        LAST NAME

Type of business the applicant is engaged in, and its relationship to
the title industry.


Type of Business Entity:

___ Corporation ___ Partnership ___ Sole Proprietorship ___ Individual


Names and titles of owners and officers of applicant.


NAME                      TITLE             LICENSE NUMBER (if applicable)


___________________________________________________________________________

___________________________________________________________________________



Is applicant a member of the American Land Title Association (ALTA)?
      ______(Yes)     ______(No)



Is applicant licensed to engage in any other class of insurance including
title insurance? 
      ______(Yes)     ______(No)



Please briefly explain why you are interested in becoming an Affiliate
member of the New Jersey Land Title Association.


___________________________________________________________________________



REFRENCES


A minimum of two references are required, both of which must be an active or
agency member in good standing with the New Jersey Land Title Association.

1.  Name of Active Member _________________________________________________

    Name of personal reference ____________________________________________

2.  Name of Person _________________________________Tel# __________________

    Address _______________________________________________________________

    City, State, Zip ______________________________________________________

3.  Name of Person _________________________________Tel# __________________

    Address _______________________________________________________________

    City, State, Zip ______________________________________________________


Send application to New Jersey Land Title Association:

Attention:   Edward C. Eastman, Jr. Executive Director,
             Monmouth Executive Center, 100 Wilow Brook Rd,
             Building 1, Freehold, New Jersey  07728 
             along with an application of $100.00 made payable to NJLTA


Membership is subject to approval by the Board of Governors of the NJLTA.

THANK YOU FOR YOUR INTEREST IN THE NEW JERSEY LAND TITLE ASSOCIATION.