Name

Address of home you want to sell

Address (cont.)

City

State/Province

Zip/Postal Code

Work Phone

Home Phone

FAX

E-mail

Do you currently                                                      Select One Rent Own

If you own, will you have to sell your present home in order to buy?  Select One Yes No

Is your home currently listed?                                 Select One Yes No

Do you have a buyer?                                             Select One Yes No

When is your closing date?

Have you spoken with a lender?                             Select One Yes No

If yes, have you been pre-qualified?                       Select One Yes No

If pre-qualified, how much?

If you rent, when will your lease be up?

Why you are moving?

How long have you been looking?

Do you live in the area?                                         Select One Yes No

Will you be buying in the near future?                   Select One within the next 30 days within the next 60 days within the next 90 days within the next 6 months within the next year No, just looking

How many homes have you looked at so far?

When would you ideally like to be settled in?

How much do you currently have budgeted for a house payment?

How much money do you have available for a down payment?

Best time to contact you?                                      Anytime Morning (8a-12p)                                                                    Afternoon (12p-6p) Night (6p-10p)

How did you hear about us?                                Select one Craigslist Ad Newspaper Ad Search Engine Street Sign Referral (please mention this when we contact you) Tear Flyer Other

Who referred you?

Please give us any additional information that can help us find a solution for you