Application for Affiliate Membership

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QUESTIONNAIRE AND APPLICATION
FOR AGENCY MEMBERSHIP
IN THE
NEW JERSEY LAND TITLE ASSOCIATION
AGENCY SECTION

(Full Name of Company & Producer License Number)

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 title of owners and officers of application who have a 5% or more interest in the Agency and License number

Name	Title	License 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,
         New Jersey Land Title Association,
         Monmouth Executive Center, 100 Willowbrook Rd, Building 1, Freehold, NJ  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.

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Application for Affiliate Membership

Get A Blank Agency Application form to Print