DATE: __________________,         TELEPHONE NUMBER:_______________________

BROKER NAME:___________________________________________________________

COMPANY NAME:__________________________________________________________

STREET ADDRESS:________________________________________________________

CITY, STATE & ZIP:________________________________________________________

BROKER'S MASSACHUSETTS LICENSE #:____________________________________

CLIENT'S NAME:__________________________________________________________

IF CORPORATE, AUTHORIZED AGENT'S NAME:________________________________

CLIENT'S TELEPHONE #:________________________

CLIENT'S SIGNATURE ACKNOWLEDGING YOUR REPRESENTATION:

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I, _____________________________, DO THIS THE ________ DAY OF _________________, HEREBY STATE THAT I AM ACTING IN MY CAPACITY AS A BROKER WITH THE ABOVE REFERENCED CLIENT, IN REGARD TO THEIR INTENDED PURCHASE OF THE REAL PROPERTY LOCATED AT 270 MAIN STREET, AGAWAM, MASSACHUSETTS. I FURTHER STATE THAT I AM NOT A PRINCIPLE IN, NOR WILL I HAVE ANY FUTURE OWNERSHIP INTEREST IN THE PURCHASE OF 270 MAIN STREET, AGAWAM, MASSACHUSETTS.

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