I am moving from   City    State

I am moving to   City     State

I anticipate moving   Month Choose One: JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER     Year

Would you like an information packet about your destination city?  Yes    No

I need a broker/agent to assist me with: (Please check all that apply)

        Purchasing my next home

        Selling my present home

        Leasing my next home

        Leasing/property management of my present home

I need a home with:

        Number of Bedroom Choose one: 1 Bedroom 2 Bedrooms 3 Bedrooms 4 Bedrooms More than 4 Bedrooms

        Number of Bathrooms Choose One: 1 Bath 2 Baths 3 Baths More than 3 Baths

        Price Range   Minimum    Maximum 

Additional Requirements

My Contact Information (* required)

        *Name 

        Address 1

        Address 2 

        City     State    ZIP 

        *Daytime Phone:  Area Code      Number   

        *Evening Phone:  Area Code      Number   

        *Email Address   

Are you currently working with an Agent?   YES     NO