First Name *

Last Name *

Email *

Phone *

Date of birth *

Address

Street Address *

City *

State *

Country

Postal code *

Emergency Contact Name *

Relationship to Emergency Contact *

Emergency Contact Phone Number *

I am most responsive to: (check all that apply) *

Phone Call

Email

Text

Which office do you intend to be your primary location? *

Whitemarsh

Bel Air

Canton

Choose your MD license status: *

Activating a new Maryland license

Transferring an existing Maryland license

MD DLLR License # *

If you are ACTIVATING a license, please provide your REGISTRATION number.

MD License Issue Date *

DLLR Password

Full SSN: *

City and State of Birth *

Mother's Maiden Name *

Bright MLS ID #

Have you ever been convicted of a felony or misdemeanor in any State or Federal court? *

Yes

No

Have you ever had a real estate license denied, suspended, or revoked by Maryland or any other state? *

Yes

No

Have you ever been convicted of any drug offense committed after January 1, 1991? *

Yes

No

I’m an employer required to provide employee coverage under Workers Compensation Law? *

Yes

No

If yes, provide the Policy # and Insurance Company:

I hereby certify under the penalty of the law that the information herein is true to the best of my knowledge and belief. I AUTHORIZE the release of any information in this application to an authorized representative of DLLR for further investigation. I further CERTIFY that I have paid all undisputed taxes and unemployment insurance contributions or have provided for payment in a manner satisfactory to the unit responsible for collection. *

Yes

Binding Sponsorship - who was most influential in you joining Keller Williams?

Choosing a sponsor is a very important decision that you must consider wisely as the person you choose will be your sponsor for life. The Profit Share System & Growth Sharing Program were implemented to reward Keller Williams Realty associates and employees for helping build the company by attracting additional talented and productive members. The spirit of the system is that your sponsor is that person whom you feel is primarily responsible for bringing you to Keller Williams Realty.

Sponsor Name: *

Who from Keller Williams influenced your decision to join our brokerage? Please provide a name.

By signing this Offer of Affiliation, I acknowledge and agree to the following: *

I am choosing to transfer my active Maryland real estate license to Keller Williams Gateway (KWG)

I understand that all required paperwork, technology setup, and board/orientation scheduling will take place at my Onboarding Meeting

Provide your payment information to complete your affiliation with Keller Williams Gateway.

Name on Card *

Card Number *

Card Expiration *

Card Security Code *

Card Billing Zip Code *