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* First Name:
* Last Name:
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Address:
City:
State:	AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:
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General Information About Your Move
Where are you moving?
State:	AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:
When do you anticipate purchasing your new home?	select one within 4 months within 6 months within a year no date set
Information About The Home You Are Looking For
Type of Home:	Single Family Condo/Townhouse Multi-family Mobile Home Farm Land Only
Approximately priced between:	select one $0 $10,000 $20,000 $30,000 $40,000 $45,000 $50,000 $55,000 $60,000 $70,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $400,000 $450,000 $500,000 $550,000 $600,000 $650,000 $700,000 $750,000 $800,000 $850,000 $900,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000 $3,500,000 $4,000,000 $4,500,000 $5,000,000 $6,000,000 $8,000,000 $10,000,000 and select one $10,000 $20,000 $30,000 $40,000 $45,000 $50,000 $55,000 $60,000 $70,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $400,000 $450,000 $500,000 $550,000 $600,000 $650,000 $700,000 $750,000 $800,000 $850,000 $900,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000 $3,500,000 $4,000,000 $4,500,000 $5,000,000 $6,000,000 $8,000,000 $10,000,000
Number of Bedrooms:	select one 1 2 3 4 5 6
Number of Bathrooms:	select one 1 2 3 4+
Interior Features & Preferences:	Living Room Family Room Fireplace Hardwood Floors Den / Study Laundry Room
Other Important Interior Features:
Exterior Features & Preferences:	Swimming pool Spa Waterfront Garage Tile roof Fenced
Other Important Exterior Features:
Additional Information
Have you ever been pre-qualified for a mortgage?	No Yes
Do you have a down payment?	No Yes
Have you had a credit report done lately?	No Yes
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• Edward P. Zagorski

• Century 21 Reale
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