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

Select a (Seller Profile System Benefit) Sell In 120 Days Guaranteed Sellers Finance and Purchase Plan Sellers Listing Increase Plan Sellers Calculated Benefits
Would you like to join our (Sellers Profile System) I want to Join Your Seller Profile System I don't want to Join Your Profile System
Would you like to (Hire Us to Sell Your Home) I Want to Hire You to Sell my Home I'm planning on Selling myself No I have an Agent (When) Immediately Within 1 Month Within 3 Months Within 6 Months In a Year or more
(Are you Purchasing another Home) I'm not Repurchasing I Have chosen another Home I'm still looking (Do You Need Pre-Approval for the Difference) I'm Pre-Approved I need Pre-Approval

Please tell us more about your home:
 
How long have you (Known of Us) 3 Months+ 6 Months+ 9 Months+ 12 Months+ One Year+ 2 Years+ 3 Years+ 4 Years+ 5 Years+ 6 Years+ 7 Years+ Longer (Who Referred You) Friend Family Coworker Previous Borrower Previous Buyer Previous Seller Cable TV Billboards Direct Mail Flyers Park Benches Posters Road Advertising Magazine Newspaper Sign Search Engine Telemarketing Other Advertising Another Site Web Site Word of Mouth None of the Above