Needs Assessment
*
indicates a required field
Name
*
First:
*
Last:
Current Address
*
Address:
*
City:
*
State:
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
*
Zip:
Contact Information
*
Must provide at least one of the following, depending on your preferred contact method
Home Phone:
Cell Phone:
Email Address:
*
Preferred Contact Method:
Email
Telephone
Your Needs
*
Are you interested in Selling or Purchasing a home?
Selling
Purchasing
Both
*
If purchasing a home, are you already pre-approved for a mortgage loan?
Yes
No
Not Applicable
*
Will this be within the next:
1 to 3 months
4 to 6 months
7 to 12 months
more than 1 year
*
Property Type:
Single Family
Townhome
Condominium
*
How many levels:
Any
1
2
3
4
*
# of Bedrooms:
Any
1
2
3
4
5
*
# of Bathrooms:
Any
1
1.5
2+
3+
4+
5+
*
Approximate value of home if Selling:
*
Price range of home if Purchasing:
Comments:
