SouthStar Broker Application

SouthStar Capital Broker Application

Broker's Name*

First Name

Last Name

Company Name (if broker is incorporated)

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number*

Email*

Fax Number

Social Security Number*

Federal Tax ID #

Applicant understands that SouthStar Capital, LLC may make reference inquires and that it may, at its sole expense, order credit reports and/or independent background investigations on the applicant and/or its principal officers. I/We authorize and direct any party to provide SouthStar Capital, LLC, and/or any holder of this form working with or representing SouthStar Capital, LLC, any and all information and documentation in which they may request. Such information includes, but is not limited to, mortgage balances and payoffs, judgment lien payoffs, employment history and income, bank, money market and similar account balances, credit histories and reports. I affirm that all answers and information submitted in this application are true and correct. I have authorized SouthStar Capital, LLC at its discretion, to verify the information with any other sources and I hereby waive any cause of action or claim I may have against such source with respect to any information they may provide. A copy or fax of this authorization may be accepted as an original. Your prompt reply is appreciated. The following information is used for the purpose of verifying this application with outside sources.

Principal Officer 1*

First Name

Last Name

Title*

DOB*

Social Security #*

% of Ownership*

Signature

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Date

Principal Officer 2

First Name

Last Name

Title

DOB

Social Security #

% of Ownership

Signature

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Date