Disaffiliation Form to CCIAOR/CCI & MV MLS

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.

Effective Disaffiliation Date *

Agent Name *

Real Estate License Number *

Member/U#

This agent's Active, Pending and Temp Off Market listings will (choose one): *

Please indicate the reason for disaffiliation: *

Company Name: *

Designated REALTOR®/Responsible Broker/Office Manager Name *

Designated REALTOR®/Responsible Broker/Office Manager Email *

Notes to CCIAOR/CCIMLS:

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. *

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If you have any questions regarding the disaffiliation process, please contact support@cciaor.com.