Name:

Phone:

Address:

City:

State: Zip:

E-Mail:

Civilian or Military: Civilian Military Ages of Children:

Do you wish to buy, rent or sell a home? Buy Rent Sell

VA Eligible? Yes No Have You Ever Purchased A Home Before: Yes No

Do You Own A Home: Yes No

Prefer: City Country

Price Range: $ Up to 50000 50000 to 75000 75000 to 100000 100000 to 125000 125000 to 150000 150000 to 175000 175000 to 200000 200000 and up

Type of Home: New Townhouse Condo Existing Mobile Modular Style of Home: Ranch 2-Story Brick Traditional Contemporary Cape Cod Cottage Split-Level Split-Entry Tudor Salt Box

Number of Bedrooms:

Number of Baths:

Do you require a garage?

Choose miscellaneous features:

Fireplace Bonus Room Pool Fenced Yard Hardwood Floors

Great Room Fenced Yard Formals Ceiling Fans Formal Areas

What would you like your move-in date to be?

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Additional Comments: