Agent Data Sheet

Name

Name *

Preferred Name or Nickname

Preferred Name or Nickname

License Type

License Type * BrokerManaging broker

RE License Number (Insert full number, ie 475.---). Type Pending if newly licensed.(required)

RE License Number (Insert full number, ie 475.---). Type Pending if newly licensed.(required) *

Your Preferred Phone Number

Your Preferred Phone Number *

Email

Email *

Realtor Association Membership (Click on Your Answer)

Realtor Association Membership (Click on Your Answer) * Chicago (CAR)Main Street (MORe)North Shore-Barrington (NSBAR)Three RiversNone (To join)

MLS ID # (State None if the case)(

MLS ID # (State None if the case)( *

County of Residence

County of Residence * CookDeKalbDuPageKaneKendallLakeMcHenryWillOther

Previous Brokerage Company

Previous Brokerage Company *

Primary Product Type

Primary Product Type * ResidentialCommercialInvestmentResidential & CommercialResidential & InvestmentCommercial & InvestmentAll

Please List Any Language Spoken Other Than English

Please List Any Language Spoken Other Than English *

Home Address 1

Home Address 1 *

Home Address 2

Home Address 2

City

City *

State

State *

Zip Code

Zip Code *

Home Telephone

Home Telephone

Cell Phone

Cell Phone

Fax Number

Fax Number

Are You Male or Female?

Are You Male or Female? * MaleFemale

Your Website URL, if any

Your Website URL, if any

Emergency Contact Name

Emergency Contact Name *

Emergency Phone Number

Emergency Phone Number

Relationship (Type spouse, sister, son, partner, etc.)

Relationship (Type spouse, sister, son, partner, etc.)

Street Address

Street Address

City, State and ZIP

City, State and ZIP

Plan: Type Silver or Gold. (Silver is $35/mo, Gold is $100/mo)

Plan: Type Silver or Gold. (Silver is $35/mo, Gold is $100/mo) *

Birthdate (MM/DD/YY, i.e. 01/20/78)

Birthdate (MM/DD/YY, i.e. 01/20/78) *

Date Joining Charles Rutenberg Realty (i.e. 04/15/2024)

Date Joining Charles Rutenberg Realty (i.e. 04/15/2024) *

If real estate is not full time, what is your primary occupation?

If real estate is not full time, what is your primary occupation?

How Did You Hear About Charles Rutenberg Realty?

How Did You Hear About Charles Rutenberg Realty? * Mailing/FlyerReferralEmailTelephone CallInternet SearchAdvertisementRejoiningWord of Mouth

If Referred, What is the Name of the Person Who Referred you? (Please type in first and last name.)

If Referred, What is the Name of the Person Who Referred you? (Please type in first and last name.) *