Please Provide Your Contact Information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Any Alternate Phone Number?

When is the Best Time to Call You?

How Long Have You Lived at This Address?

How Many Bedrooms Do You Want?

1 2 3 4 +

What City/Town or Area Do You Want to Move to?

What Type of Apartment Do You Want (i.e., duplex, condo, full house, apt.)?

What Floor Do You Want to Be On (i.e., 1st, 2nd)?

1st 2nd 3rd Any

When Do You Want to Move?

Why Are You Moving?

About How Much is Your Household's Monthly Income?

        Select One under $500 $500-$1,000 $1,000-$1,200 $1,200-$1,500 $1,500-$1,700 $1,700-$2,000 over $2,000

How Much Do You Want to Spend for Rent? Please Enter Just One Amount.

under $300 $350-$400 $450-$500 $550-$600 $650-$700 $750-$800 $850-$900 $950-$1,000 over $1,000

How Many Adults Will Be Living With You, Including Yourself?

1 2 3 4 +

How Many Children Will Be Living With You?

none 1 2 3 4 +

How Many Cars Do You Have?

1 2 3 4 +

Do You Have a Section 8 Voucher?

Yes No

Do You Have Any Pets?

Yes No

If Yes, How Many and What Kind of Pets?

How Did You Hear of Us?

Do You OR Anyone In Your House Smoke?

Yes No

Which of the Following Do You Want:

Washer/Dryer Hookups  Near or On Busline    Garage                Shower              
Coin-Op Laundry       Yard                  Cable Ready           Tub                 
Hardwood Floors       Carpeting             Stove & Refrigerator  Gas Heat & Hot Water
Oil Heat              Non-Smoking Apt.      Storage               Near to Highway     

Any Additional Comments?