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

  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 - No Mortgage Own - w/ Mortgage Own - w/ Contract for Deed Own - w/ Lease Purchase
   
Selling Time Frame *  [Pick One] 30 Days or Less 60 Days or Less 90 Days or Less Over 90 Days

Approx. Price Range  $

   Subdivision Name 

Reason for selling * 

Remarks - Questions - Comments      

Acknowledgement:

I am not currently represented by or working with another Realtor.
I understand and want Seller Representation. I will sign a Listing Representation Agreement with Blakeman Properties.

* I Agree