This form authorizes RatePlug to affiliate the Brokerage with the Lender(s) specified below. RatePlug will abide by the authorizations provided by the Broker Owner listed below. If you have additional questions please contact Brad Springer at (630) 848-1335.

Broker Name: _____________________________________________________________________

Company: _______________________________________________________________________

Address: ________________________________________________________________________

City, State and Zip: ________________________________________________________________

Work #: (____) - ____________________ Cell #: (____) - _________________

Fax #: (____) - ____________________ Broker ID: ______________Affiliated MLS: GALMLS

E-mail Address: ___________________________________________________________________

_______Will your Brokerage allow your Agents to select additional lending partners of their choice.
Yes or No.

_______ Does your Brokerage have an Affiliated Lender(s) that you wish to activate in this program?
Yes or No.
                  If Yes, please list Lender(s) information below

AFFILIATED LENDER(S) CONTACT INFORMATION:

1) LO Name:                                                                                                                                     

Company:                                                                                         Work #: (____) - ____________

Address:                                                     City:                               State:                          Zip:            

Email Address:                                                                                                                                       

2) LO Name:                                                                                                                                     

Company:                                                                                         Work #: (____) - ____________

Address:                                                     City:                               State:                          Zip:            

Email Address:                                                                                                                                       




3) LO Name:                                                                                                                                     

Company:                                                                                         Work #: (____) - ____________

Address:                                                     City:                               State:                          Zip:            

Email Address:                                                                                                                                       



________________________________________  ______________________
Broker Owner Signature                                                 Date
Please Print and Fax completed form to: (630) 848-1337