Microsoft Word - Exclusive Right to Sell Unimproved Land

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 1 of 10

EXCLUSIVE RIGHT TO SELL UNIMPROVED LAND LISTING AGREEMENT

This Exclusive Right to Sell Unimproved Land Listing Agreement (“Agreement”) is made on

(Date) by and between

(“Seller”) and (Insert Firm Name)

(“Broker”).

1. APPOINTMENT OF BROKER. In consideration of the services provided by Broker and

described in this Agreement, Seller hereby appoints Broker as Seller’s sole and exclusive listing

agent and grants Broker the exclusive right to sell the real property described below (“Property”).

2. PROPERTY.

Street Address

City , Virginia ZIP Code

TAX Map/ID #

Historic District Designation

Legal Description:

 Lot/Block/Subdivision:

Lot(s) Block/Square Section Phase

Subdivision or Condominium

County/Municipality Deed Book/Page #

 Metes/Bounds, see attached description or survey.

Approximate Square Footage/Acreage:

Owner is aware of the following easements, covenants, variances, and restrictions:

3. NOTICES. All notifications and amendments under this Agreement shall be in writing and shall be

delivered using the contact information below.

Seller

Mailing Address:

City, State, and ZIP Code:

Phone: (H) (W) (Cell)

Email: Fax:

Broker (Firm)

Mailing Address:

City, State, and ZIP Code:

Phone: (W) (Cell)

Email: Fax:

4. TERM OF AGREEMENT. This Agreement shall run for the period commencing after signature by

all parties and expiring at 11:59 p.m. on (“Listing Period”). If a sales contract for

Property is ratified during Listing Period which provides for a settlement date beyond Listing Period,

this Agreement shall be extended automatically until final disposition of the sales contract.

5. LISTING PRICE. Seller instructs Broker to offer Property for sale at a gross sales price of

 $ OR  $  per square foot OR  per acre, or such other

price as later agreed upon by Seller, which price includes Broker’s compensation. (Note: Broker

does not guarantee that Property will appraise or sell at the price stated hereunder, nor does Broker

guarantee any net amount Seller might realize from the sale of Property).

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 2 of 10

6. UTILITIES; MAJOR SYSTEMS. (Check all that apply, if any)

Water Supply:  Public  Community Well

 Private Well Well Approved by County  Yes or  No Location:

Sewage Disposal:  Public  Septic Approved by County if so, for Bedrooms

Type of Septic System:  Community  Conventional  Alternative  Experimental

Location of Septic System:

Section 32.1-164.1:1 of the Code of Virginia requires Seller to disclose whether the onsite septic

system serving Property is operating under a waiver of repair and/or maintenance requirements

imposed by the State Board of Health. If the septic system is operating pursuant to a waiver, then

Seller must provide the buyer with the “Disclosure Regarding Validity of Septic System Permit”

prior to contract ratification. Such waiver is not transferable to the buyer.

Seller represents that the septic system  is OR  is not operating under a waiver from the State

Board of Health.

Electricity:  Onsite OR  Available (Location if known: )

Natural Gas:  Onsite OR  Available (Location if known: )

Cable:  (Location if known: )

Fiber optics:  (Location if known: )

Other:  (Location if known: )

7. BROKER DUTIES. Broker shall perform, and Seller hereby authorizes Broker to perform, the

following duties. In performing these duties, Broker shall exercise ordinary care, comply with all

applicable laws and regulations and treat all parties honestly.

A. Broker shall protect and promote the interests of Seller and shall provide Seller with services

consistent with the standards of practice and competence that are reasonably expected of licensees

engaged in the business of real estate brokerage. Seller acknowledges that Broker is bound by the

bylaws, policies and procedures, and rules and regulations governing the MLS, the Code of Ethics of

the National Association of REALTORS®, the Code of Virginia, and the Regional Rules and

Regulations for the electronic lockbox system.

B. Broker shall use reasonable efforts and act diligently to seek buyers for Property at the price and

terms stated herein or otherwise acceptable to Seller, to negotiate on behalf of Seller, to establish

strategies for accomplishing Seller’s objectives, to assist in satisfying Seller’s contractual

obligations, and to facilitate the consummation of the sale of Property.

C. Broker shall market Property, at Broker’s discretion, including without limitation, description,

photographs in appropriate advertising media, such as publications, mailings, brochures and internet

sites; provided, however, Broker shall not be obligated to continue to market Property after Seller

has accepted an offer.

D. Broker shall present all written offers or counteroffers to and from Seller in a timely manner,

even if Property is subject to a ratified contract of sale, unless otherwise instructed by Seller in

writing.

E. Broker shall not continue to market, show and/or permit showings after Property is subject to a

ratified contract of sale, unless otherwise instructed by Seller in writing.

F. Broker shall account, in a timely manner, for all money and property received in trust by Broker,

in which Seller has or may have an interest.

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 3 of 10

G. Broker shall show Property during reasonable hours to prospective buyers and shall accompany

or accommodate, as needed, other real estate licensees, their prospective buyers, inspectors,

appraisers, exterminators and other parties necessary for showings and inspections of Property, to

facilitate and/or consummate the sale of Property. Broker agrees that the showing instructions to be

shared in the MLS with other real estate licensees and their prospective buyers are as follows:

Broker  shall OR  shall not install an electronic lockbox on Property to allow access and

showings by persons who are authorized to access Property.

H. Broker  shall OR  shall not install “For Sale” signs on Property, as permitted. Seller is

responsible for clearly marking the location of underground utilities, equipment, or other items that

may be damaged by the placement of the sign.

8. MARKETING/MLS/INTERNET ADVERTISING.

A.  Seller authorizes OR  Seller does not authorize Broker to market Property via the Multiple

Listing Service (“MLS”).

1) If Seller authorizes Broker to market Property in MLS, Broker shall disseminate, via MLS,

information regarding Property, including listing price(s), final sales price, all terms, and all

status updates during and after the expiration of this Agreement. Broker shall enter the listing

information into MLS  within three (3) business days of commencement of the Listing Period

OR  on or before: .

In either event, Broker shall enter the listing information into MLS within one (1) business day

of Public Marketing of Property. “Public Marketing” includes, but is not limited to, displaying

flyers in windows, yard signs, digital marketing on public facing websites, brokerage website

displays (including internet data exchanges and virtual office websites), digital communications

marketing (email blasts), multi-brokerage listing sharing networks, and applications available to

the general public.

2) If Seller does not authorize Broker to market Property via MLS, Broker shall instead

Publicly Market Property by such other methods as Broker deems appropriate in accordance with

MLS rules and regulations, Virginia law and this Agreement. Seller shall sign and deliver

concurrently with this Agreement a “Waiver of Broker Submission to MLS” form or other

acceptable certification that Seller does not authorize Broker to Publicly Market the listing via

MLS. Broker shall submit such waiver or other certification to MLS within three (3) business

days of execution of this Agreement.

B.  Seller authorizes OR  Seller does not authorize Broker marketing Property through MLS to

also make listing data available to third party websites. Seller understands that the listing data may

get disseminated to third party websites through means other than MLS regardless of the selection

above. Seller acknowledges that the accuracy of the listing data is controlled by the third-party

websites and is outside of Broker’s control. The parties agree and understand that third party

websites include: 1) Broker’s internet website; 2) the internet websites of licensed real estate

salespersons or associate real estate brokers affiliated with Broker or other brokers participating in

MLS; 3) any other internet websites (such as syndicated websites) in accordance with applicable

MLS rules and regulations; and/or 4) printed media.

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 4 of 10

C. In the event Seller has opted into marketing Property in the MLS in subparagraph A above,

Broker is hereby authorized by Seller to submit and market Property as follows:

 Seller authorizes OR  Seller does not authorize the display of Property address on any internet

website. In the event Seller does not authorize the display of the property address, only the ZIP

code will be displayed.

 Seller authorizes OR  Seller does not authorize the display of unedited comments or reviews

of Property (or display a hyperlink to such comments or reviews) on MLS participants’ internet

websites. This provision does not control the display of such comments on third-party websites

such as syndicated websites.

 Seller authorizes OR  Seller does not authorize the display of an automated estimate of the

market value of Property (or a hyperlink to such estimate) on MLS participants’ internet

websites. This provision does not control the display of such estimated value of Property on

third-party websites such as syndicated websites.

D.  Seller authorizes OR  Seller does not authorize Broker to list Property under “coming soon”

status in MLS. If Seller authorizes Broker to list Property under “coming soon” status in MLS,

Broker shall list Property under “coming soon” status in MLS  within three (3) business days of

commencement of the Listing Period OR  on or before: . Property may be

listed in the MLS under “coming soon” status for no more than 21 days from the date the listing is

entered in MLS, except when a longer period is permitted by applicable MLS rules and regulations.

Broker may engage in pre-marketing activities prior to the date that Property is entered in MLS

under “active” status including, but not limited to: 1) placing a “coming soon” sign on Property; 2)

notifying agents with other firms that Property is “coming soon”; and 3) placing advertisements and

conduct other marketing activities at Broker’s discretion. Broker shall not show Property to

prospective buyers or tenants and/or their agents while under “coming soon” status.

E. During the term of this Agreement, Seller may, by written notice to Broker, authorize Broker to

enable or disable use of any feature as described above. Broker agrees to update MLS database

accordingly.

9. TYPES OF REAL ESTATE REPRESENTATION - DISCLOSURE AND INFORMED

CONSENT.

Seller representation occurs by virtue of this Agreement with Seller’s consent to use Broker’s

services and may also include any cooperating brokers who act on behalf of Seller as subagent of

Broker. (Note: Broker may assist a buyer or prospective buyer by performing ministerial acts that are

not inconsistent with Broker’s duties as Seller’s listing agent under this Agreement.)

Buyer representation occurs when buyers contract to use the services of their own broker (known

as a buyer representative) to act on their behalf.

Designated representation occurs when a buyer and seller in one transaction are represented by

different sales associate(s) affiliated with the same broker. Each of these sales associates, known as a

designated representative, represents fully the interests of a different client in the same transaction.

Designated representatives are not dual representatives if each represents only the buyer or only the

seller in a specific real estate transaction. In the event of designated representatives, each

representative shall be bound by client confidentiality requirements, set forth in the

CONFIDENTIAL INFORMATION paragraph. The broker remains a dual representative.

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 5 of 10

 Seller does not consent to designated representation and Seller does not allow Property to be

shown to a buyer represented by this Broker through another designated representative associated

with the firm OR

 Seller consents to designated representation and allows Property to be shown to a buyer by this

Broker through another designated representative associated with the firm.

Dual representation occurs when the same broker and the same sales associate(s) represent both the

buyer and seller in one transaction. In the event of dual representation, the broker shall be bound by

confidentiality requirements for each client, set forth in the CONFIDENTIAL INFORMATION

paragraph.

 Seller does not consent to dual representation and Seller does not allow Property to be shown to a

buyer represented by this Broker through the same sale associate OR

 Seller consents to dual representation and allows Property to be shown to a buyer by this Broker

through the same sale associate.

An additional disclosure is required before designated or dual representation is to occur for a

specific transaction.

Broker will notify other real estate licensees via the MLS of whether Seller consents to designated

representation and/or dual representation.

10. BROKER COMPENSATION.

A. Payment. Seller shall pay Broker in cash total compensation of

(“Compensation”) if, during the term of this Agreement, anyone produces a buyer ready, willing and

able to buy Property.

Compensation is also earned if, within days after the expiration or termination of this

Agreement, a contract is ratified with a ready, willing, and able buyer to whom Property had been

shown during the term of this Agreement; provided, however, that Compensation need not be paid if

a contract is ratified on Property while Property is listed with another real estate company.

B. Cooperating Broker. Broker shall make a blanket unilateral offer of cooperation and

compensation to other brokers in any MLS that Broker deems appropriate. To that end, Broker shall

offer a portion of Compensation to the cooperating broker as indicated:

Buyer Agency Compensation: OR

Other Compensation:

Note: Compensation may be shown by a percentage of the gross selling price, a definite dollar

amount or “N” for no compensation.

Broker’s compensation and the sharing of compensation between brokers are not fixed, controlled,

recommended or suggested by any multiple listing service or association of REALTORS®.

C. Variable Rate Commission. If applicable, the Broker and Seller agree to a variable rate

commission to be paid as follows: .

D. Retainer Fee. Broker acknowledges receipt of a retainer fee in the amount of

which  shall OR  shall not be subtracted from Compensation. The retainer fee is non-

refundable and is earned when paid.

E. Early Termination. In the event Seller wishes to terminate this Agreement prior to the end of

Listing Period, without good cause, Seller shall pay Broker before Broker’s

execution of a written release.

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 6 of 10

11. CONFIDENTIAL INFORMATION. Broker shall maintain the confidentiality of all personal and

financial information and other matters identified as confidential by the client which were obtained

by Broker during the brokerage relationship, unless the client consents in writing to the release of

such information or as otherwise provided by law. The obligation of Broker to preserve confidential

information continues after termination of the brokerage relationship. Information concerning

adverse material facts about Property is not considered confidential information.

12. AUTHORIZATION TO DISCLOSE OTHER OFFERS. In response to inquiries from buyers or

cooperating brokers, Broker may not disclose, without Seller’s authorization, the existence of other

written offers on Property. If Seller does give such authorization, Seller acknowledges that Broker

and sales associate(s) must disclose whether the offers were obtained by the listing agent, another

member of the listing Broker’s firm, or by a cooperating broker.

Seller  does OR  does not authorize Broker and sales associate to disclose such information to

buyers or cooperating brokers.

13. COMPLIANCE WITH FAIR HOUSING LAWS. Property shall be shown and made available

without regard to race, color, religion, sex, handicap, familial status, or national origin as well as all

classes protected by the laws of the United States, the Commonwealth of Virginia and applicable

local jurisdictions, or by the REALTOR® Code of Ethics.

14. CONDOMINIUM ASSOCIATION. Seller represents that Property  is OR  is not located

within a development which is a Condominium or Cooperative. Condominiums or Cooperatives

being offered for sale are subject to the receipt by buyers of the required disclosures, and Seller is

responsible for payment of appropriate fees and for providing these disclosure documents to

prospective buyers as prescribed in the Condominium Act, Section 55.1-1900, et seq., and the

Cooperative Act, Section 55.1-2100, et seq., of the Code of Virginia.

 Seller OR  Broker shall order the association disclosure documents at Seller’s expense

 at the time of listing OR  within 3 days following the date of contract ratification OR 

__________________.

The Condominium or Cooperative dues are $ per

(frequency of payment).

Special Assessment $ for

Condominium or Cooperative Association Name:

Management Company: Phone #:

Seller represents that Seller  is OR  is not current on all condominium association dues and/or

special assessments.

15. PROPERTY OWNERS’ ASSOCIATION. Seller represents that Property  is OR  is not

located within a development(s) which is subject to the Virginia Property Owners’ Association Act,

Section 55.1-1800, et seq., of the Code of Virginia. If Property is within such a development, Seller

is responsible for payment of the appropriate fees and for providing these disclosure documents to

the buyers.

 Seller OR  Broker shall order the association disclosure documents at Seller’s expense

 at the time of listing OR  within 3 days following the date of contract ratification OR 

__________________.

The Property Owners’ Association dues are $ per

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 7 of 10

(frequency of payment).

Special Assessment $ for

Property Owners’ Association Name:

Management Company: Phone #:

Seller represents that Seller  is OR  is not current on all property owners’ association dues

and/or special assessments.

16. CURRENT LIENS. Seller represents to Broker that the below information is true and complete to

the best of Seller’s information, knowledge and belief and Seller understands that any loans

identified below will be paid off at Settlement: (check all that are applicable)

A.  Property is not encumbered by any mortgage or deed of trust (if box is checked, skip to G).

B.  Property is security for a first mortgage or deed of trust loan held by (Lender Name):

with an approximate balance of $ .

This loan is a  Conventional OR FHA or VA or  .

C.  Property is security for a second mortgage or deed of trust loan held by (Lender Name):

with an approximate balance of $ .

D.  Property is security for a line of credit or home equity line of credit held by (Lender Name):

with an approximate balance of $ .

E.  Seller is current on all payments for the loans identified above.

F.  Seller is not in default and has not received any notice(s) from the holder(s) of any loan

identified above, or from any other lien holder of any kind, regarding a default under any loan,

threatened foreclosure, notice of foreclosure, or the filing of foreclosure.

G.  There are no liens secured against Property for federal, state, or local income taxes; unpaid

real property taxes; or unpaid condominium or homeowners’ association fees or special assessments.

H.  There are no judgments against Seller (including each owner for jointly held property). Seller

has no knowledge of any matter that might result in a judgment that may potentially affect Property.

I.  Seller has not filed for bankruptcy protection under federal law and is not contemplating

doing so during the term of this Agreement.

In the event Property is encumbered by a loan, Seller further agrees that Seller shall promptly

disclose the name and contact information for the lender and account number to the Settlement

Agent identified in a contract for the sale of the Property. During the term of this Agreement, should

any change occur with respect to answers A. through I. above, Seller shall immediately notify

Broker and sales associate/listing agent, in writing, of such change.

17. SELLER FINANCING. Seller  does OR  does not agree to offer seller financing by providing

a deed of trust loan in the amount of $ with further terms

to be negotiated.

18. CLOSING COSTS. Fees for the preparation of the deed of conveyance, that portion of the

settlement agent’s fee billed to Seller, costs of releasing existing encumbrances, Seller’s legal fees,

Grantor’s Tax, and any other proper charges assessed to Seller will be paid by Seller unless provided

otherwise in the sales contract.

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 8 of 10

The “Seller’s Estimated Cost of Settlement” form  is OR  is not attached. These estimates are

for informational purposes only and will change based upon the terms and conditions of the purchase

offer.

19. IRS/FIRPTA. Section 1445 of the Internal Revenue Service (IRS) Code may require a buyer or the

settlement agent to report the gross sales price, Seller’s federal tax identification number and other

required information to the IRS. Seller shall provide to a buyer or the settlement agent such

information upon request. In certain situations, the IRS requires a percentage of the sales price to be

withheld from Seller’s proceeds if Seller is a Foreign Person as defined by FIRPTA.

Seller  is OR  is not a “Foreign Person” as defined by FIRPTA.

20. SELLER DUTIES.

A. Seller Representations and Warranties. Seller is aware that Seller may be responsible for

failing to disclose information and/or misrepresenting the condition of Property. Seller warrants that:

1) Seller certifies the accuracy of the information provided to the Listing Broker.

2) Seller has capacity to convey good and marketable title to Property by general warranty deed and

represents that Property is insurable by a licensed title insurance company with no additional risk

premium.

3) Seller is not a party to a listing agreement with another broker for the sale, exchange or lease of

Property.

4) No person or entity has the right to purchase, lease or acquire Property, by virtue of an option,

right of first refusal or otherwise.

5) Seller  is OR  is not a licensed (active/inactive) real estate agent/broker.

6) Seller  has OR  has no knowledge of the existence, removal or abandonment of any

underground storage tank on Property.

7) Property  is OR  is not tenant-occupied.

8) Seller  has OR  does not have a recording system in Property. In the event Seller has a

recording system in Property which records audio, Seller understands that recording of audio

may result in violation of state and/or federal wiretapping laws. Therefore, Seller hereby releases

and holds harmless Broker, Broker’s designated agents, sub-agents, sales associates and

employees from any liability which may result from the recording of audio in Property.

B. Access to Property. Seller shall provide keys to Broker for access to Property to facilitate

Broker’s duties under this Agreement. Seller shall allow Broker’s unlicensed assistants in the

Property to perform ministerial acts as defined by 18VAC135-20-165.

If Property is currently tenant-occupied, Seller shall provide Broker with any current lease

documents and contact information for current tenant and shall use best efforts to obtain the full

cooperation of current tenants, in connection with showings and inspections of the Property.

Seller’s Proceeds: Seller acknowledges that Seller’s proceeds may not be available at the time of

settlement. The receipt of proceeds may be subject to Section 55.1-903 of the Code of Virginia,

commonly referred to as the Virginia Wet Settlement Act, and may be subject to other laws, rules and

regulations (e.g. Virginia estate statutes and the Foreign Investment in Real Property Tax Act -

FIRPTA).

Seller

is

advised to seek legal and/or financial advice concerning these matters.

NVAR: K1355 v01/21 Seller: ______/______/______/______ Broker: _______________ Page 9 of 10

C. Seller Assumption of Risk.

1) Seller retains full responsibility for Property, including all utilities, maintenance, physical

security and liability until title to Property is transferred to buyer. Seller is advised to take all

precautions for safekeeping of valuables and to maintain appropriate property and liability

insurance through Seller’s own insurance company.

Broker is not responsible for the security of Property or for inspecting Property on any periodic

basis. If Property is or becomes vacant during the Listing Period, Seller is advised to notify

Seller’s homeowner’s insurance company and request a “Vacancy Clause” to cover Property.

2) In consideration of the use of Broker’s services and facilities and of the facilities of any Multiple

Listing Service, Seller and Seller’s heirs and assigns hereby release Broker, Broker’s designated

agents, sub-agents, sales associates and employees, any Multiple Listing Service and the

Directors, Officers and employees thereof, including officials of any parent association of

REALTORS®, except for malfeasance on the part of such parties, from any liability to Seller for

vandalism, theft or damage of any nature whatsoever to Property or its contents that occurs

during the Listing Period. Seller waives any and all rights, claims and causes of actions against

them and holds them harmless for any property damage or personal injury arising from the use or

access to Property by any persons during the Listing Period.

21. MISCELLANEOUS PROVISIONS.

A. Appropriate Professional Advice. Broker can counsel on real estate matters, but if Seller

desires legal advice, Seller is advised to seek legal counsel. Seller is advised further to seek

appropriate professional advice concerning, but not limited to, property or tax and insurance matters.

B. Service Provider Referrals. Broker or one of Broker’s sales associates may refer a service

provider to assist Seller in this transaction. This referral is not an endorsement, guarantee or

warranty as to the quality, cost and/or timeliness of the services to be provided. Seller is advised to

independently investigate all options for service providers and consider whether any service provider

will work effectively with Seller. Seller is free to reject any referred service provider for any or no

reason.

C. Subsequent Offers After Contract Acceptance. After a sales contract has been ratified on

Property, Broker recommends Seller obtain the advice of legal counsel prior to acceptance of any

subsequent offer.

D. Governing Law. The laws of the Commonwealth of Virginia shall govern the validity,

interpretation and enforcement of this Agreement.

E. Binding Agreement. This Agreement will be binding upon the parties, and each of their

respective heirs, executors, administrators, successors and permitted assigns. The provisions hereof

will survive the sale of Property and will not be merged therein. This Agreement, unless amended in

writing by the parties, contains the final and entire agreement and the parties will not be bound by

any terms, conditions, oral statements, warranties or representations not herein contained.

22. ATTORNEYS’ FEES. If any Party breaches this Agreement and a non-breaching Party retains

legal counsel to enforce its rights hereunder, the non-breaching Party shall be entitled to recover

against the breaching Party, in addition to any other damages recoverable against any breaching

Party, all of its reasonable Legal Expenses incurred in enforcing its right under this Agreement,

whether or not suit is filed, and in obtaining, enforcing and/or defending any judgment related

thereto. Should any tribunal of competent jurisdiction determine that more than one Party to the

NVAR: K1355 v01/21 Page 10 of 10

dispute has breached this Agreement, then all such breaching Parties shall bear their own costs.

However, if the tribunal determines that one or more of the Parties is a “Substantially Prevailing

Party,” any such Substantially Prevailing Party shall be entitled to recover from any of the breaching

Parties, in addition to any other damages recoverable against any breaching Party, all of its

reasonable Legal Expenses incurred in enforcing its rights under this Agreement, whether or not suit

is filed, and in obtaining, enforcing and/or defending any judgment related thereto. “Party” as used

in this paragraph includes any third-party beneficiary identified herein. “Legal Expenses” as used in

this paragraph includes attorney fees, court costs, and litigation expenses, if any, including, but not

limited to, expert witness fees and court reporter fees.

23. ADDITIONAL TERMS:

/ /

Date Seller Date Broker/Sales Manager

/

Date Seller

/

Date Seller

/

Date Seller

******************************************************************************

Sales Associate Contact Information

Sale Agent (Listing Agent:

Team Name (if applicable):

Phone: (W) (Cell)

Email: Fax:

Supervising Broker Contact Information

Broker Name:

Phone: (W) (Cell)

Email: Fax:

This is a suggested form of the Northern Virginia Association of REALTORS

®

, Inc. (“NVAR”). This form has been

exclusively printed for the use of REALTOR

®

members of NVAR, who may copy or otherwise reproduce this form in

identical form with the addition of their company logo. Any other use of this form by REALTOR

®

members of NVAR,

or any use of this form whatsoever by non-members of NVAR is prohibited without the prior written consent of NVAR.

Notwithstanding the above, no REALTOR

®

member of NVAR, or any other person, may copy or otherwise reproduce

this form for purposes of resale.