Appraiser Information
Appraiser Name:
Company Name
Title
Business Address
City:
State:
Zip:
Phone:
Fax:
Pager:
E-mail:
EDI Transmission Software (If applicable):
Self Employed Owner/ Officer Partner Employee
State Licensing and Certification/ Approved Products
State License Certified Number Expires
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Does applicant carry Errors and Omissions Insurance?
Yes No
Are you HUD approved?
Yes No
Are you FHA approved?
Yes No
Special properties such as REO/ FHA?
Yes No

Years of Appraising Experience?
Appraiser Coverage
Primary Countries State Secondary Countries State
Disciplinary Actions
Yes No
Have you ever been the subject of a lawsuit initiated?
Yes No
Have you ever been disciplined by a state appraisal licensing agency or professional organization?
Yes No
Have you ever had a claim filed against your Error and Omissions Insurance?
If "yes" to any above, please explain:
Minority/ Woman Owned Business
In order to maintain our files and provide reports, please check the appropriate box(s):
African American
Native American including American Indians, American Eskimos, American Aleuts and Native Hawaiians
Hispanic American from any Latin American country in South America, Central America or the Caribbean
Asian-Pacific American from Japan, China, Okinawa, the Philippines, Vietnam, Korea, Samoa, Guam, Northern Marinas, Laos, Cambodia, Taiwan and the US Trust Territories of the Pacific
Asian American Indian from India, Pakistan and Bangladesh
Woman owned business Concern a concern is at least 51 person owned, or is publicly owned business where the combined total of all classes of stock is owned by a woman who are US citizens and who also control and operate the business.  "Control" in this context shall mean exercising power to make policy decisions and "operate" shall mean being actively involved in the day-to-day management.
The submitter of this form is not a minority or women owned business.