Name: (Required)

E-mail: (Required)

Address:

City: State: Zip:

Day Telephone:

Evening Telephone:

Fax:

General Information About Your Move:

Are you Relocating?Yes    No

Where are you moving?
City: State: Zip:

When do you anticipate purchasing your new home? within 4 months within 6 months within a year no date set

Information About The Home You Are Looking For:

Type of home:

Single Family Condo/Townhouse Multi-family Mobile Home Farm Land Only

Approximately priced between: 50,000 75,000 100,000 150,000 200,000 300,000 400,000 500,000 1,000,000 1,000,000+ and 50,000 75,000 100,000 150,000 200,000 300,000 400,000 500,000 1,000,000 1,000,000+

Number of Bedrooms

1   2   3   4   5   6+

Number of Bathrooms:

1   2   3   4+

Interior Features & Preferences

Living Room	Yes    No	Family Room	Yes    No
Fire Place	Yes    No	Hardwood Floors	Yes    No
Den/Study	Yes    No	Laundry Room	Yes    No

Other Important Interior Features:

Exterior Features & Preferences

Swimming Pool Yes    No Spa Yes    No Waterfront Yes    No Tile Roof Yes    No Garage Yes    No Fenced Yes    No

Other Important Exterior Features:

Additional Information

Have you ever been pre-approved or pre-qualified for a mortgage? Yes  No

If yes, for how much?

Do you have a down payment?  Yes  No

If yes, what is your maximum commitment?

Have you had a credit report done lately?  Yes  No

If yes, any problems?  Yes  No

Please use this space for any other comments or questions you might have.