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REALTOR® REFERRAL FORM
Client Information
* My client is a:	Please Select Buyer Seller Seller & Buyer Commercial Buyer Commercial Seller
* Client Name:		* E-mail:
Address:		City:
Province/State:	Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Saskatchewan Yukon Northwest Territories --------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming --------------- Other State/Province	Postal/Zip:
Country:	Canada USA Abu Dhabi Aden Afghanistan Albania Algeria American Samoa Andorra Angola Antarctica Antigua Argentina Aruba Australia Austria Bahamas Bahrain Bangladesh Barbados Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil British Antarctica Territory British Indian Ocean Territory British West Indies Brunei Bulgaria Burundi Cambodia Cameroon Canada Canal Zone Canary Islands Canton And Enderbury Islands Cape Verdi Islands Cayman Islands Central African Republic Cevlon Chad Chan. Island UK Chile China Christmas Island Cocos (Keeling) Islands Columbia Comoro Islands Congo Congo Kinshasa Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech. Republic Dahomey Dem. People's Rebulic Of Korea Dem. People's Republic Of Yemen Dem. Republic Of Vietnam Denmark Djibouti Dominica Dominican Republic Dronning Muad Land - Antarctica Dubai Ecuador Egypt El Salvador England, UK Equatorial Guinea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland France French Guiana French Polynesia French Southern & Antarctica French Territory Of Afars & Issas French West Indies Gabon Gambia Gaza Germany Ghana Gibraltar Greece Greenland Guadeloupe Guam Guatamala Guinea Guinea Bissau Guyana Haiti Heard & Mcdonald Islands Holland Honduras Hong Kong Hungary Iceland Ifni India Indonesia Iran Iraq Iraq-Saudi Arabia Neutral Zone Ireland Israel Italy Ivory Coast Jamaica Japan Johnston Atoll Jordon Kazakhstan Kenya Korea Kuwait Laos Latvia Lebanon Leeward Islands Lesotho Liberia Libya Liechtenstein Lithuania Luxenbourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Mariana Islands Martinique Mauritania Mauritius Melanesia Mexico Micronesia Midway Islands Moldovia Monaco Mongolia Montserrat Moracco Mozambique Myanamar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles Neutral Zone New Caladonia New Hebrides New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Ireland, UK North Korea Norway Oman Pacific Island Pakistan Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Polynesia Portugal Portuguese Guinea Portuguese Timor Principe & Sao Tome Puerto Rico Qatar Republic Of Belarus Reunion Romania Russia Rwanda Ryukyu Islands S.W. Africa Sabah San Marino San Tome & Principe Saudi Arabia Scotland, UK Senegal Seychelles Sierra Leone Sikkim Singapore Slovakia Solomon Islands Somalia Somaliliand South Africa South Korea South Vemen Spain Spanish Sahara Spartly Islands Sri Lanka St. Christopher-Nevis-Anguilla St. Helena St. Kitts St. Lucia St. Pierre & Miquelon St. Vincent Sudan Surinam Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tanzania Thailand Togo Tonga Transkei Trinidad/Tobago Tunisia Turkey Turks & Caicos Islands USA US Pacific Island US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Upper Volta Uruguay Vanuatu Vatican City Venezuela Vietnam Wake Island Wales, UK West Indies Western Samoa Windward Islands Zaire Zambia Zimbabwe
Phone:		Fax:
Schedule
Date of move:	Select date Jan. - Mar. Apr. - Jun. Jul. - Sept. Oct. - Dec. Don't Know Ask the Client View Notes	Year:
Employer Relocation:	Yes No	Employer:
Financing
Prequalified:	Yes No	Lender Name:	Select Lender Alberta Treasury Branches Bank Of Montreal Bank Of Nova Scotia Canada Trust Canadian Mortgage Centres Canadian Western Bank Capital City Savings C.I.B.C. Hongkong Bank of Canada Laurentain Bank of Canada National Bank of Canada Royal Bank of Canada Toronto Dominion Bank Other
Other:		Amount:
Home needed to buy or sell
Select Price Range See Notes Up to $100,000 $100,000 - $110,000 $110,000 - $120,000 $120,000 - $130,000 $130,000 - $140,000 $140,000 - $150,000 $150,000 - $160,000 $160,000 - $170,000 $170,000 - $180,000 $180,000 - $190,000 Up to $200,000 $200,000 - $250,000 $250,000 - $300,000 Up to $300,000 $300,000 - $350,000 $350,000 - $400,000 Up to $400,000 $400,000 - $450,000 $450,000 - $500,000 Over $500,000 _____________________		Style of Home Bungalow Semi-Bungalow Bi-Level 2 Storey Split 3 Level Split 4 Level Split 5 Level Split 2 Storey 2 1/2 Storey 3 Storey ______________________
Select Baths See Notes 1 Bath 1 1/2 Bathrooms 2 Bathrooms 2 1/2 Bathrooms 3 Bathrooms 4 Bathrooms 5 or more baths ______________________		Select Bedrooms See Notes 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5+ Bedroom _____________________
Select Age See Notes New Up to 5 Years Up to 40 years Not a concern ______________________		Select Size See Notes Up to 1000 sq. ft. 1000 - 1500 sq. ft. 1500 - 2000 sq. ft. 2000 - 2500 sq. ft. 2500 - 3000 sq. ft. 3000 - 3500 sq. ft. Over 3500 sq. ft. _____________________
Select Parking See Notes Carport OK Single garage attached Single garage detached Double garage attached Double garage detached Triple garage attached Tripe garage detached Not a concern ______________________		Type of Home Single Family Detached Single Family Attached Duplex Half Duplex Triplex Low-Rise Apartment Hi-Rise Apartment Townhouse Carriage Quadplex Vacant Lot _____________________
Additional Notes:
Client's preferred method to receive updates
Phone Fax Email Postal Service
Agent Information
* Sales Rep Name:		* Agency:
Branch or location:		E-mail:
Mailing Address:		City:
Telephone:		Pager:
Fax:		Cellular:
Agent's preferred method to receive updates
Phone Fax Email Postal Service
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