American Midwest Real Estate Consultants, Inc.

American Midwest

REFERRAL FEE REGISTRATION FORM

Name Of Referring Party

Address1 (Referring party):	Address2 (Referring party):
City (Referring party):	State (Referring party):
Zip Code (Referring party):
Phone # (Referring party):	Fax Number (Referring party)

Amount of Loan Requested:	Name Of Loan Asset To Be Registered:
Address Of Asset 1:	Address Of Asset 2:
City - Asset Location	State - Asset Location
Zip Code - Asset Location	Name - Borrower Contact
Address - Borrower Contact 1	Address - Borrower Contact 2
City - Borrower Contact	State - Borrower Contact
Zip Code - Borrower Contact	Phone Number - Borrower Contact
Fax Number - Borrower Contact

36 Four Seasons Center, Suite 336 St. Louis, MO 63017 Phone: 800-707-2699 Fax: 314-878-7755
4515 Madison, Suite 200 Kansas City, MO 64111 Phone: 800-707-0045 Fax: 816-751-0543