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Broker Information Form
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Company Information:
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| Company Name |
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| Your Name: . | ||||
| Address | ||||
| City | ||||
| State.. | ||||
| Zip Code | ||||
| Business Phone: | ||||
| Business Fax: | ||||
| Business Email: | ||||
| Broker of Record: | ||||
| Broker Phone: | ||||
| Fed. Tax ID No. | ||||
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Banking Information:
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| Bank is authorized and directed to mail all banking information on this account including but not limited to our monthly bank statements, canceled checks, analysis and returned items. |
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| Mail attention to: | ||||
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Ascendant Escrow |
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| Virtual Escrow Technology Department | ||||
| 19900 Beach Blvd suite C-2 | ||||
| Huntington Beach, CA 92648 | ||||
| List Authorized Signers: (Include Drivers Lic. And Social Security numbers for each signer) | ||||
| Name | Drivers Lic. | Social Security | ||
| Name | Drivers Lic. | Social Security | ||
| Name | Drivers Lic. | Social Security | ||
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COPIES OF DRIVERS LICENSES ARE REQUIRED FOR ALL
AUTHORIZED SIGNERS
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| List of Personnel to be trained on software: | ||||
| Name: | Name: | Name: | ||
| Name: | Name: | Name: | ||
| Name: | Name: | Name: | ||
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