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ABOUT YOU:
First Name
Spouses Name
Last Name
Home Number ( )
Work Number ( )
Fax Telephone ( )

E-mail Address  
Street Address
City
State Alaska Alabama Arizona Arkansas California Colorado Connecticut Dist.of Columbia Delaware Wash., D.C. 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Wash. State W. Virginia Wisconsin Wyoming Outside U.S. Zip
Your SS# Your Credit History Excellent 720-800 Good 680-720 Fair 620-680 Bad 400-620
Spouses Spouses Credit History Excellent 720-800 Good 680-720 Fair 620-680 Bad 400-620
What is Your Request Home Purchase & Loan Approval Refinance & Loan Approval Sell my Home Time Frame Immediately In 1 Month In 2 Months In 3 Months In 6 Months Within A Year
How did You Heard about Us Another Agent/Broker Another Web Site Brochure Commercial Co-worker Flyer Friend or Family Member Internet Mail Newspaper Phone Call Past Client Street Ad Word of Mouth None of the Above

Comments, Questions and/or Suggestions:

Please Tell Us How You Heard About Our Services Another Agent/Broker Another Web Site Bill Boards Brochures Cable Commercial's Conference Co-worker Direct Mail Family Member Flyer Friend Lender Magazine Newspaper Open House Previous Client Park Benches Posters Road Advertising Road Advertisement Search Engine Sign Special Function Special Reports Suzette's Sunday Tour of Homes Telemarketing Television Word of Mouth None of the Above
Select Your Request I need consultation I need pre-approval I'd like to buy I'd like to sell When Immediately In 1 Month In 2 Months In 3 Months Within 6 Months Within A Year