Name:

 Address:

 City: State: Zip:

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 Home Phone:     Business Phone:   

 Mobile Phone:   Fax:

 What is a good time to contact you?

 Do you currently own or rent?    (Please check one)   own:Rent: Other:

 What is your time frame for moving? (Please check one)    Within a week: Two weeks or less: Within one month: 1-2 months:    2-6 months:Within one year: Not sure:

 How many bedrooms do you need? (Please check one)  1: 2: 3: 4:5 or more:

 How many bathrooms do you need? (Please check one)  1: 1 1/2: 2: 2 1/2:3 or more:

 What price are you considering?

 Have you been approved for a mortgage? (Please check one)  Yes: No:

 Do you need to sell a home before you buy? (Please check one)  Yes: No:

 Any other comments regarding your home search?