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I. Contact Information

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The following information must be supplied in full:

	First Name:	Last Name:	# Children:

	Primary E-Mail Address:
	Daytime Phone:    Evening Phone:
	Address: City: State/Territory: Zip Code:    (select a state below) Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Will your employer be assisting you or be offering you a relocation benefits package?         Yes         No                         Employer (If Job Related Move):                                                  Employer Address:                                                  City, State Zip:

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II. Desired Features In Buyer's New Home

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What kind of information are you interested in?         Mortgage and Lending         Moving Companies         Employment Information         School Information         Community Information        Other (Please Describe)         Do you also have a home to sell?    (Complete Section III if "Yes")         Yes         No Have you been prequalified by a lender:         Yes         No What is the destination city, state and/or area?         What other information is important for your agent to know?

What is the target date of your move?        Month  (select a month) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec        Year       Are you a first-time home buyer?         Yes         No How many people will live in the home?         What size home is needed?         Minimum Bedrooms         Minimum Baths         Minimum 1/2 Baths         Minimum Square Footage Do you prefer New Construction?         Yes         No         Either Age of home would you consider purchasing?        Minimum Age:  Years        Maximum Age:  Years What is your desired price range?        Min:       Max:

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III. Features Of Home to be Listed For Sale

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What is your primary motivation for selling?         Relocating away to New Area         Moving Locally to Smaller/Larger Home         Job Transfer         Need To Liquidate Assets        Other (Please Describe)         Will your employer be assisting you in selling your home?         Yes         No By what date would you like to have your home sold?        Month  (select a month) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec        Year       Home/Property Information:         Bedrooms         Bathrooms         Square Footage         Acre(s) Lot Size         Year Built

Type Of Property?          (select a type) Condo Townhouse Detached Home Mobile Home Vacant Lot Commercial/Retail Is the property occupied?:         Yes         No       If yes, occupant's contact information:             Name             Telephone Number Is the property currently listed with a REALTOR?         Yes             No        If yes, with which broker/firm:                      Listing Company Phone:                      Listing Expiration Date:               Is this move definite and within the next 6 months?:         Yes         No

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Please list any other information that we need to know before contacting you:

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REQUIRED ACKNOWLEDGMENT AND PERMISSION TO CONTACT

         I acknowledge that a real estate consultant will call me by telephone to verify the above information and that I will be referred to a local specialist to personally assist me in my real estate needs.   Although I agree to a brief "compatibility meeting," I understand that I am under no obligation to hire the specific agent referred to me.

Yes                                 No