Va. Code Ann. § 54.1-2139.01
B. Such disclosure may be given in combination with other disclosures or provided with other information, but if so, the disclosure shall be conspicuous, printed in bold lettering, all capitals, underlined, or within a separate box. Any disclosure which complies substantially in effect with the following shall be deemed in compliance with this disclosure requirement:
DISCLOSURE OF DUAL AGENCY OR DUAL REPRESENTATION IN A COMMERCIAL REAL ESTATE TRANSACTION
The undersigned do hereby acknowledge disclosure that:
The licensee _____________________ (name of broker or salesperson) associated with____________________ (Brokerage Firm) represents more than one party in this commercial real estate transaction as follows:
Brokerage Firm represents the following party (select one):
[ ] Seller(s) [ ] Buyer(s) [ ] Landlord(s) [ ] Tenant(s)
As a (select one):
[ ] agent [ ] independent contractor
Brokerage Firm represents another party (select one):
[ ] Seller(s) [ ] Buyer(s) [ ] Landlord(s) [ ] Tenant(s)
As a (select one):
[ ] agent [ ] independent contractor
The undersigned understand that the foregoing dual agent or dual representative may not disclose to either client any information that has been given to the dual agent or representative by the other client within the confidence and trust of the brokerage relationship except for that information which is otherwise required or permitted by Article 3 (§ 54.1-2130 et seq.) of Chapter 21 of Title 54.1 of the Code of Virginia to be disclosed.
The undersigned by signing this notice do hereby acknowledge their informed consent to the disclosed dual representation by the licensee.
____________ _______________________
Date Name (One Party)
____________ _______________________
Date Name (One Party)
____________ _______________________
Date Name (One Party)
____________ _______________________
Date Name (One Party)
2012, c. 750; 2016, c. 334; 2025, cc. 479, 495.