| Name (First & Last) |
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| Spouse/Other
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| Your Current Contact Information |
| Street Address |
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| City |
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| State/Province |
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| Zip/Postal Code |
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| Home phone with area code |
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| Work phone number - optional
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| Best time to call |
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Area of Relocation |
| City |
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| State |
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| How soon do you plan to buy |
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Your Requirements |
| Price Range |
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| Number of bedrooms needed |
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| Number of bathrooms needed
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| Type of home
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| Desired Location
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| Age of home
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| Do you have a home to sell |
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| How did you find this web site
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| Have you been pre-qualified |
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| Would you like information on financing
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| Have you contacted
other Realtors? |
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