Agent Disaffiliation Form

This form is to be filled out by the Designated REALTOR® (i.e. Broker-in-Charge) or authorized Office Manager of a company and is used to disaffiliate an agent from your company. Please allow 1 business day for the agent to be removed from your CCIAOR and/or CCIMLS office roster.

Please Note –Designated REALTOR®/Broker-in-charge/Office Manager signature is required.
Please indicate the reason for disaffiliation: *
Please Note –Designated REALTOR®/Responsible Broker/Office Manager signature is required.

By signing below, I confirm that I am a Designated REALTOR® or authorized Office Manager and that the agent listed above is no longer affiliated with my company and will be removed from my company's CCIAOR and/or CCIMLS company roster. I understand it is my responsibility to notify the State of Massachusetts when a licensee is no longer affiliated with my company seperate from completing this form.  *
If you have any questions regarding the disaffiliation process, please contact 
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