EquityRock – The EquityRock Agreement

Become An Originator

Application

Company Information

Legal Name of Company*

Doing Business As (DBA)*

Street Address*

City*

State*

Zip*

Telephone*

Fax

Primary Contact to Verify Company Information

First Name*

Last Name*

Title*

Telephone*

Email*

Institution and Business Type

Institution Type*

Business Type*

Organized Under the Laws of (State)*

Year Incorporated/Established*

Federal Tax ID #*

Is the Firm subsidiary of another entity?*

Yes No

If yes, who is the parent?

Investor/Lender and Mortgage Insurance Companies References

List 3 investors/lenders/MI companies with whom you are currently doing business.
Company*	Contact Person*	Telephone*

Warehouse Line Information (Applicable* Yes No)

List 3 investors/lenders/MI companies with whom you are currently doing business.
Warehouse Lender	Contact Person	Commitment Amount	Telephone

Other Information

Has the company or its Principals or Licensee ever had its real estate/lending license revoked, suspended or denied?*	Yes No

Has the company or its Principals filed bankruptcy or been involved with any entity that has filed bankruptcy?*	Yes No

Has the company or its Licensee had any complaints filed against it within the last 2 years?*	Yes No

Are there any outstanding or pending litigation, claims, contingencies, judgments, liens or tax delinquencies?*	Yes No

Has the company ever been suspended or terminated by and investor, lender, or agency?*	Yes No

General Certification
By entering my initials below, the undersigned hereby: (1)declares, on behalf of the Company, that the statements set forth herein are true and complete; (2)authorizes REX & Co. ("REX"), to obtain verification from any source named herein as to the accuracy of the information provided and to obtain credit information regarding the company as part of its approval process; (3)releases, discharges, exonerates and covenants not to sue any person or entity providing information to REX in connection with this application, and any recipient of such information, including REX or its representatives, from any and all liability of every nature and kind arising from or in connection with the furnishing, receipt, and review of such information.
Legal Name of Company*
Authorized Signer Name*
Authorized Signer Title*
Authorized Signer DOB*
Authorization Date*
Authorization Initials*