Referring Agent/Broker First and Last Name:

Office Name:


City, State, Zip:


Phone Number:


All referrals submitted are subject to pre-qualification. In order to process referrals timely, we need all required fields to be filled out when submitting the form online, blank fields may result in the delay of processing.

Referring Agent/Broker acknowledges that the United Referral Network provides a concierge service through UC-SCS. To cover administrative costs of the program, UC-SCS charges a 35% referral fee to the Receiving Agent/Broker. In the event Receiving Agent/Broker receives a commission or other payment for services rendered in connection with a real estate transaction consummated involving the Referred Client, Referring Agent/Broker will be entitled to a 25% referral fee. Referring agent remains responsible for any fees owed to his/her brokerage.


Client Name:


City, State, Zip:

Clients Email:

Clients Phone:

Client is looking to:

Reason for Buying / Selling:

Relationship with Client:

Special Instructions (If Applicable):


Selling: Estimated Property Listing Price

Address of Property to Be Sold:

Client Must Sell By:

Selling: Property Type

Description of the Property to be Sold:


Buyers Price Range:

Desired Timeframe to Buy:

Buyers Desired Property Type:

Buyers Preferred Area:

Buyers Requirements or Preferences:


I, Referring Broker/Agent, acknowledge this referral is a customer and/or client with whom I have made personal contact and have vetted as being a ready, willing and able customer/client. I acknowledge that, through the United Referral Network, UC – Strategic Client Services’ purpose is to assist ready, willing and able customers/clients with their real estate needs and that third party leads or cold leads DO NOT meet the standard qualifications for this program. Failure to adhere to this standard qualification may result in being barred from this program’s use. By checking the box, you are agreeing to the terms outlined within the acknowledgement.

I Accept*

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