1. Today's Date :

   
   

2. Please provide the following contact information:

   First name
   Last name
   Title
   Street address
   Address (cont.)
   City
   State/Province
   Zip/Postal code
   Country
   Work Phone
   Home Phone
   FAX
   E-mail

3. Type of property desired:

   Vacation Home
   Permanent Residence
   Commercial
   Land
   

4. Select the features desired:

   3+ Bedrooms  2 Bedrooms 1 Bedroom	3+ Bathrooms      2 Bathrooms 1 Bathroom
   Log      Chalet   Ranch   Condo	Custom - Design to Build  New Construction  Established - 1-5 Year Construction  Established - 6 + Year Construction
   View Central Air Conditioning

5. Price Range of Residential / Vacation Home Property:

Up to $100,000
$101,000 - $150,000
$151,000 - $199,000
$200,000 - $250,000
Above $250,000

Price Range of Land / Lot:

Up to $20,000
$21,000 - $35,000
$36,000 - $50,000
$51,000 & Above

I plan to purchase property:

Now
Within the Next 3 Months
3 - 6 Months
6 - 12 Months
In a Year or Two
Just Curious

8. Are you currently working with another Real Estate Broker ? If so, please identify the name of your agent.