Receiving Agent Information
Agent Name:
Office Name:
Address:

City:

State/Prov:
Zip/PC:
Country:
E-mail:
Primary Phone:
Cell Phone:
Fax Nuymber:
   
Sending Agent Information
Agent Name:
Office Name:
Address:

City:

State/Prov:
Zip/PC:
Country:
E-mail:
Primary Phone:
Cell Phone:
Referring Tax ID:
Fax Nuymber:
Client Information
Name: Current Home Phone Number:
Current Address: Current Work Phone Number:
City Cell Phone Number:
State/Prov: Number of Adults in move:
Zip/PC: Next Date of Home Finding Trip:
Country Expected Move Date:
Additional Info:    
Current Property Information
Client is a: Estimated property listing price: Must Clients sell first:
Has client been pre-qualified? Lender Information: Reason for move:
Desired Property Information
Price Range: Est. Down Payment: Desired Monthly Payment:
Preferred Home Style: Number of Bedrooms:
Number of Bathrooms: Square Footage:
Familiar with the area: Preferred Area:
School Requirements: Additional Requirements:
Referral Agreement Details
By signing this form as the receiving agent, you aggree to have your broker-in-charge pay the following referral fee, to the sending agent's broker-in-charge, for the benefit of the following sending agent.
The receiving Agent's Name: Total Referral Fee (% or$ ammount):
The Sending Agent's Name::
Percentage-based referral fees will be based on commissions earned on the:
Other (please specify):
Sending Agent Signature: Date Signed:
Receiving Agent Signature: Date Signed::




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