Life Service Member Application Form

Name
First Last
Firm Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Name of local Association
QUALIFICATIONS
Member of Oregon REALTORS® for not less than twenty-five (25) cumulative years:
Member since:
Must be at least sixty-five (65) years of age, or have experienced a permanent health disability:
Birth Date:
Date Format: MM slash DD slash YYYY
Permanent Health Disability (explain):
Notable Service to Oregon REALTORS® (Oregon REALTORS® Service required -- must be completed)
Please outline your past and present service to Oregon REALTORS® for a minimum of 3 years; including committees and years served.
Notable Service to your local Association (Must be completed)
Please outline your past and present service on local committees in detail, including committees and years served.
OR
Notable Service to your community
• Volunteering with an accredited community program or charity • Serving on a City or County committee, board, council, or commission • List the organizations and years served:
Signature
I certify that the above information is accurate and verifiable.
First Last
Date
Date Format: MM slash DD slash YYYY
Current Resume (attach copy)*
Application is considered incomplete if resume is not attached

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