First Name:       M.I.       Last Name:

Street Address:

City, State, Zip:

Home Phone:       Work Phone:

E-mail Address:

The Best Way to Contact You: E-mail Phone Mail

Price Range: Under $100,000 $100,000 - $150,000 $150,000 - $200,000 $200,000 - $250,000 $250,000 - $300,000 $300,000 - $350,000 $350,000 - $400,000 Over $400,000

Are you Interested in:
   Buying    Selling    Both

What is your Timeframe?
   30 Days    60 Days    90 Days    Over 90 Days

Would you like Financing Information?   Yes   No

If yes, please fill out the following questions.

Amount for Downpayment:

Type of loan you are interested in:
   30-year mortgage   15-year mortgage   ARM

Annual Income:

Monthly Debts:

Other features I desire in buying or selling a home.