Customer Intake Form
First Name
Last Name
Date of Birth
Email
Phone Number
Address
City
State
Zip Code
Race





Household Income



Hispanic Ethnicity? (Select if you are)

Gender

Marital Status




Current Housing Arrangement




Are you a first time home buyer?

Are you a veteran?

Hosehold Type






Referred to by
Are you currently working with a real state agent?

Have you own a home in the last three (3) years?

If so, agent's name:
Agent's phone number
Do you have a pre-approval from a lender? if so, which one?
Authorization