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

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


Type of Business Entity:
  Corporation Partnership Sole Proprietorship Individual

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
    
    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.

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