Name: **

Street Address: **

Address Line 2:

City: **

Province:

Postal Code:

Phone: **

E-mail:

Are you planning to sell your home in the next six months?

< .. > Yes No

On a scale of 1-5, please rate the condition of your home:

< .. > 1 - Very Poor 2 - Poor 3 - Average 4 - Above Average 5 - Excellent

Style of Home:

Type of Home:

< .. > Detached Semi-Detached Townhouse Condo Other

Lot Size (approximate):

Square Footage (approximate):

Age of Home:

Type of Heating:

< .. > Oil Electric Other

# of Bedrooms:

< .. > 1 2 3 4 5+

# of Bathrooms:

< .. > 1 2 3 4 5+

Finished Basement:

< .. > Yes No

List any special features, or provide any additional relevant details: