Conflict of Interest Disclosure Form

1. Agent Information

Agent Name: License Number: Agency Name:

2. Client Information

Client Name(s): Property Address:

3. Nature of Conflict

Please describe the potential or actual conflict of interest:

4. Disclosure Details

Details of disclosure to client:

5. Acknowledgment

I acknowledge that I have disclosed to my client(s) all potential or actual conflicts of interest in accordance with applicable laws and regulations.