Affiliation Form to CCIAOR/CCIMLS/MVMLS

New Agent Affiliation Form

This form is to be filled out by the Designated REALTOR®/Responsible Broker/Office Manager and is used to affiliate an agent with a company.

This is a supplementary form that will accompany the new agent’s Membership Application HERE. *This is NOT the Membership Application*

Please note that this form can also be used to affiliate a current/active member with a company.

Effective Affiliation Date: *

Agent Name *

Real Estate License Number *

License Type *

Agent's Primary Phone Number *

Agent's Email Address *

Company Name: *

Company Address: *

City *

State *

Zip Code *

Office Phone Number *

Designated REALTOR®/Responsible Broker/Office Manager Name *

Please enter your email address to be copied on your new agent's welcome email. *

Please Note –Designated REALTOR®/Responsible Broker/Office Manager signature is required.

By signing below, I confirm the agent listed above has become affiliated with my office and will be added to my CCIAOR and/or CCIMLS office roster. I understand it is my responsibility to notify the State of Massachusetts when a licensee has become affiliated with my office in addition to this form. *

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