CONFIDENTIAL

Please provide your contact information:

First Name
Last Name
Work Phone
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Address
City
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Your Buying Needs

Are you looking to Buy, Lease Option, or Rent?

What area(s) are you looking in?

How soon are you looking to move / purchase your next home?

Choose one ASAP 1 month 2 months 3 months 4 months 5 months 6 months 7 months or more

How many bedrooms do you require?

Choose one Any 1 or more 2 or more 3 or more 4 or more 5 or more

How many bathrooms do you require?

Choose one Any 1 or more 2 or more 3 or more 4 or more 5 or more

How many square feet do you require?

Choose one 800-1000 sq ft 1100-1400 sq ft 1500-1800 sq ft 1900-2200 sq ft 2300-2800 sq ft 3000 sq ft or more

Do you require a garage?

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Do you require multiple stories?

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Do you have any other special requirements?

Your Credit Information

What's the most you can afford to pay monthly for your new home?

Choose one $600-$800 $800-$1000 $1000-$1500 $1600-$2000 $2000-$2500 $2500-$3000 $3000 or more

What's the most you can you afford to put down on your home?

Choose one $2000-$4000 $4000-$6000 $6000-$8000 $8000-$10,000 $10,000-$15,000 $15,000-$20,000 $30,000 $40,000 $50,000 or more

What price range house are you looking for?

$20,000 $50,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $600,000 or more $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $600,000 $600,000 or more

Are you employed?

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How is your credit?

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Have you ever had a Bankruptcy, Foreclosure, Repo, Eviction or Judgements?

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Are you working with a Mortgage Broker?

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If not, would you like us to refer you to one?

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Do you have any additional questions or comments?

How did you hear about us?

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