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Questionnaire and Application for Agency Membership in the New Jersey Land Title Association Agency Section

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;

Full Name of Company & Producer License Number

Name of applicant

Signature

Business Address

City

State

County

Phone

Fax

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

First Name

Middle Initial

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)?

Is applicant licensed to engage in any other class of insurance other than
title insurance?

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.

Questionnaire and Application for Affiliate Membership in the New Jersey Land Title Association

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;

Full Name of Company & Producer License Number

Name of applicant

Signature

Business Address

City

State

County

Phone

Fax

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

First Name

Middle Initial

Last Name

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

Type of Business Entity:

Names and titles of owners and officers of applicant.

Name Title License Number

Is applicant a member of the American Land Title Association (ALTA)?

Is applicant licensed to engage in any other class of insurance including
title insurance?

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

References

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:
Telephone:
Address:
City:
State:
Zip:

3.

Name of Person:
Telephone:
Address:
City:
State:
Zip:

Send application to New Jersey Land Title Association:

Attention: Edward C. Eastman, Jr. Executive Director,
Monmouth Executive Center, 100 Willowbrook 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.