PERSONAL INTEREST DISCLOSURE AND CONSENT FROM LICENSEE FOR REFERRAL OF A SERVICE VENDOR TO A BUYER

[ As Required by Tennessee License Law ]

On occasion, when asked by a party to a real estate transaction, a Real Estate Licensee may recommend the services of a service vendor:

· Who may offer the Licensee a referral fee for that recommendation;

· With whom a relative or family member of the Licensee may have personal interest;

· With whom the Licensee has a personal interest ( indirect or direct ).

Tennessee Law requires that a Licensee’s personal interest in these situations be disclosed.

[ As used in this Disclosure Form: “Buyer” shall mean Buyer or Tenant ]

DISCLOSURE OF LICENSEE’S PERSONAL INTEREST IN A REFERRAL FOR SERVICES

The Licensee named below has recommended that Buyer use the services of

_________________________________________________________________________________

Buyer has been advised of the Licensee’s interest in the Provider of Services as

_________________________________________________________________________________

and /or that Licensee shall receive compensation of for this referral.

TO BE SIGNED PRIOR TO THE USE OF THE RECOMMENDED SERVICE VENDOR

Licensee's Signature_________________________________________ Date:_____________________

Licensee's Printed Name______________________________________ Date:_____________________

Buyer's Signature ___________________________________________ Date:_____________________

Buyer's Signature ___________________________________________ Date:_____________________