Personal Information:
(Required Fields)	*Your Name:
	* E-mail Address:
	Phone
	Present Address:
	Home Phone:
	Work Phone:
(Optional)
	Occupation:
	Interests:
Home Requirements:
	Desired Locations(s):
	Price Range:
	Age of Home:
	Number of Bed Rooms:	1 2 3 4 5 6+
	Number of Baths:	1 2 3 4 5 6+
	Master Bath
	Basement Bath
	Main Floor Bath
	Garage:	Attached Detached One Car Two Car Three Car Four Car
	Fireplace:	Yes No Maybe
	Lot Size:	City Lot 55x150 Suburban Lot 95x155 Acreage Specify
	Other Acreage:
	Kitchen:	Eat-In Standard Gourmet
	Family Room:	Main Floor Basement Either
	Formal Dining Room:	Yes No Maybe
	Exterior:	Brick Stucco Wood Vinyl/Metal Hardboard Other Any
	Fenced Backyard:	Yes No Maybe
	Water:	No On the River On a Lake Pond Creek Any
	Laundry:	Main Floor Second Floor Basement Any
	Basement:	Walkout Daylight Full Basement Any

Near Schools:
	Elementary
	Secondary
	High School
	College

Home Styles:
	Rambler	Cape Cod
	1.5 Story	Victorian
	Two Story	Contemporary
	Split Entry	Tudor
	Three level	Colonial
	Four Level	Salt Box
	Other:

Charm:
	Natural Woodwork
	Hardwood Floors
	"Painted Lady"
	Built-In Buffet
	Other:

Special Features:
	Deck:	Yes No Maybe
	Hobby Farm:	Yes No Maybe
	Mother-In-Law Apartment:	Yes No Maybe
	Pool:	No In-Ground Above Ground Either
	Other important items not mentioned which need special emphasis:

	Would you like Jeff to examine your home and present you with a no obligation market evaluation and innovative marketing program?
	Yes No

If you are currently working with an agent and want to continue that relationship, please do not submit this form.