First Name 

Last Name 

Address     

City                        State

Zip             

Daytime Phone   Evening Phone   

E-mail                

1. Are you looking to buy a :

Home Second Home Vacation Property Investment Property Townome / Condo

within the next?

30 Days 30-90 Days 90 Days -1 Year More than 1 Year

2. What area are you looking in?

3. What is your price range?

$0-$49,999 $50,000-$69,999 $70,000-$89,999 $90,000-$109,999 $110,000-$129,999 $130,000-159,999 160,000-189,999 $190,000-$229,999 $230,000-$259,999 $260,000-$499,999 $500,000-699,999 $700,000-$999,999 $1Million Plus

4. Bedrooms

2 3 4 5 6+

5. Bathrooms

1 2 3 4 5+

6. Square Feet

<1200 1200-1399 1400-1699 1700-1999 2000-2299 2300-2599 2600-2899 2900-3299 3300-3699 3700--3999 4000 Plus

7. Special Features

8. Would you like to receive a Newsletter via e-mail from our office periodically.       

  Yes       No

9. Do you need a free Market analysis of your current home?

  Yes      No

10. Would you like to be contacted by a loan officer?

  Yes          No

Please answer all questions and fill in all blanks.