C O N F I D E N T I A L    Contact Information First Name* Primary Phone Last Name* Other Phone Address* Email* City*     State Please Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip* Best Time to Call Please Select Anytime Morning Afternoon Evening             Your Property Requirements What is the largest monthly payment you can afford? Please Select $250 $300 $350 $400 $450 $500 $550 $600 $650 $700 $750 $800 $850 $900 $950 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,250 $2,500 $2,750 $3,000 $3,250 $3,500 $3,750 $4,000 $4,250 $4,500 $4,750 $5,000+ What's the most you can afford to put down on your home? Please Select $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 $4,500 $5,000 $5,500 $6,000 $6,500 $7,000 $7,500 $8,000 $8,500 $9,000 $9,500 $10,000 $12,500 $15,000 $17,500 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000+ What is your price range? between Please Select $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 and Please Select $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $600,000 $700,000 $800,000 $900,000 $1,000,000+ How is your credit? Please Select Excellent Good Fair Poor Ugly No Credit How soon are you looking to purchase your next home? Please Select ASAP 1 month 3 months 6 months 9 months 12 months+ In which area(s) do you wish to purchase your home? How many bedrooms do you require? Please Select Any 1 or more 2 or more 3 or more 4 or more 5 or more How many bathrooms do you require? Please Select Any 1 or more 2 or more 3 or more 4 or more 5 or more How many square feet do you require? Please Select 500 sq ft or more 700 sq feet or more 1000 sq ft or more 1250 sq ft or more 1500 sq ft or more 2000 sq ft or more 2500 sq ft or more 3000 sq ft or more 3500 sq ft or more 4000 sq ft or more I require a... Basement Garage How did you hear about us?         Other Special Requirements Additional questions or comments: