Name * 
Spouse Name    Address * 
City *      State *    Zip * -

Employer  

  Is Employer paying your Relocation Costs? *  [Pick One] Yes No Don't Know

E-Mail Address * 

Telephone:          Home *         Fax  
    Work *        Fax 
    Spouse Work           Fax 

Current Home Status *  [Pick One] Own My Home Own My Home - Which is SOLD Own My Home - Which is FOR SALE Rent an Apartment Rent a Home / Condo Live with Parents / Relatives
   
Moving Time Frame *  [Pick One] 30 Days or Less 60 Days or Less 90 Days or Less

  New Home Price Range *  $

Source of Funds for Purchase * [Pick One] Paying Cash Pre-Approved for Loan Not Pre-Approved

   Pre-Approved Loan Amount $

Mortgage Co

Loan Officer    Phone

Remarks - Questions - Comments      

Acknowledgement:

• I am not currently represented by or working with another real estate agent or broker.

• I understand and want Buyer Representation.

• I will sign a Buyer Representation Agreement with Blakeman Properties.

*I Agree:   Yes  No

Thank You.  You will be contacted soon.