Resale Certificate Application

Resale Certification Application

Member Information
First Name *
Last Name *
2nd Member First Name
2nd Member Last Name
Phone # *
Email Address *
Closing Date *

Month Day Year
Date

ALCA Property Information
ALCA Address *
Property Type *

House with Septic House with Sewer Lot Lot with Sewer

Realtor Information
Agent First Name
Agent Last Name
Agent Phone #
Agent Email

Payment
Total Price of Resale

Payment Amount

USD Resale Certificate

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty: