Your Name:	Email Address:	Street Address:	City:
State:	Zip Code:	Phone:	Fax:

Have you read the Consumer Notice? Yes No

Are You Currently Working With An Agent? Yes No

When Do You Want To Move? 1-3 months 3-6 months 6-12 months   How Long Have You Been Looking? 1month 3-6 months 6-12 months

Where Would You Like To Live? Haverford Township Radnor Township Lower Merion Township Philadelphia Plymouth Township Upper Merion Township Whitemarsh Township What Is Your Price Range? $150,000 - $250,000 $250,000 - $350,000 $350,000 - $450,000 $450,000 - $550,000 $550,000 - $650,000 $650,000 - $750,000 $750,000 and up

Number of Bedrooms? 2 3 4 5 or more Number of Bathrooms? 2 3 4 5 or more

Describe Your Perfect Home For Me:

How Do You Want To Be Contacted? E-Mail Phone