Name
Street Address
City
State
Zip Code
Work Phone
Home Phone
FAX
E-mail
Number of Bathrooms:
Number of Bedrooms:
Time Frame to Purchase:	1 to 3 Months 3 to 6 Months 6 to 9 Months 9 to 12 Months
Have you been Pre-Qualified for a Mortgage?	Yes No
Do you need assistance in finding a Mortgage?	Yes No
Do you need to sell your Home?	Yes No
Do you have a Building Lot? If so, where?	Yes No
Best time to contact you?
Any Additional Comments for Us?