Name  

Current Address  
   

Email Address

Home Phone

Business Phone (if applicable)            Extension (if applicable)
                            

CURRENT HOME INFORMATION

Age:    1 to 5 years     6 to 10 years     Older Home

Style:    Contemporary     Ranch     Colonial     Split-Level    
Cape Cod      
Other

Development:    Townhouse     Condo     Senior Development    
Gated Community
Other

Construction:    Brick     Frame
Other

Land:     Subdivision    
Acreage
Other

Rooms:    # of Bedrooms     # of Full Baths    
# of Half Baths
Other

Additional Rooms:    Living Room     Family Room    
Library/Study    Recreation    Formal Dining    
Dining Area     Breakfast Area/Nook     Wet Bar
Other

Basement:    Yes     No

Garage:    Attached     Detached     # of Autos

Anticipated Vacancy Date:   

Anticipated Sales Price Range:   
$ to $

Comments: