BUYER INFORMATION Email * First Name * Last Name * Address * City * State * - Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Phone * Alt Phone How did you hear about us?     - Select One - Drive By Realtor Friends Internet Direct Mail Piece Newspaper Other

PURCHASE PREFERENCE Timeframe * - Select One - Immediately Less Than 3 Months 3-6 Months 6-12 Months No. of Bedrooms * - Select One - 1 2 3 Price Range * - Select One - $155,000-$200,000 $201,000-$260,000 $261,000-$290,000 Reason of Purchase * Investment Primary Residence Second Home Additional Features Requested

REALTOR INFORMATION Are you represented by a Real Estate Agent? * Yes   No If yes, please provide the following Agent Information * Agent Name Firm Phone Comments