I would like information on the following:

City:     State: 

Can we refer an outstanding agent in your area to assist in selling
your current home?   Choose One Yes No

Form of communication preferred:   Choose One E-Mail Phone Fax

May an agent contact you? Choose One Yes No
School information needed?  Choose One Yes No  
Children Ages: 
Kid Packet?  Choose One Yes No
Housing Information?  Choose One Yes No  
Rental Information:  Choose One Yes No
Price Range: 
Time Frame of Move: 
Job Transfer?  Choose One Yes No  
Name of Employer: 
Cost Comparison of Our Area?  Choose One Yes No

Any Specifics or Comments?

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