being a Title Insurance Producer duly licensed by the New Jersey Department
of Insurance, does hereby make application for Agency 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


___________________________________________________________________________

Names and titles of owners and officers of applicant and License Number


Name                      Title               Licence Number


___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________



List below all Title Companies for which the applicant is an agent.


___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________



Year in which the applicant was first licensed as a title insurance
agent/producer by the Department of Insurance? ________

What other states besides New Jersey is the applicant licensed as a title
insurance  agent/producer?

___________________________________________________________________________



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

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


Please list below all licensed title producers employed by the applicant,
set forth herin.


___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


A minimum of three references are required.
 ONE must be an ACTIVE MEMBER (Title Insurance Company) which applicant
   is agent for, and
 TWO must be AGENCY MEMBERS in good standing with the NJLTA.

1.  Name of Title Company _________________________________________________

    Name of personal reference ____________________________________________


2.  Name of Title Agent Member ____________________________________________

    Name of personal reference ____________________________________________


3.  Name of Title Agent Member ____________________________________________

    Name of personal reference ____________________________________________


Send application to:
         Edward C. Eastman, Jr.,
         Executive Director,
         Monmouth Executive Center, 100 Wilow Brook Rd,
         Building 1, Freehold, New Jersey  07728

  along with membership dues for the current year made payable to:
        NJLTA, Agency Section, in the amount of $250.00

Membership is subject to approval by the Agency Section Membership Committee and the Board of
Governors of the NJLTA.

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