Name *:

Present Address:

Purchase Address:

Home Phone *:
Fax:

Work Phone:
Fax:

Spouse/SO Work Phone:

Cell:
Spouse/SO Cell:

Email *:
Spouse/SO Email:

Employer *:
Spouse/SO Employer:

Your Birthday (MM-DD-YYYY) *:
Spouse/SO Birthday (MM-DD-YYYY):

Please list the name and birthdays of any children living with you:

Pets:

Were are you from originally?
Spouse/SO?

Please list your favorite in the following categories:

Food/Restaurant?
Spouse/SO?

Books to Read?
Spouse/SO?

Sport, Hobby, Activity? *
Spouse/SO?

Music/Band?
Spouse/SO?

Do you expect your income to be changing at any time in the next three to five years?

How long do you plan to live in this house?

What is most important to you about your overall financial planning strategy at this time?

When we communicate with you going forward, what is your preferred form of communication?
EmailPhoneMail

Do you foresee incurring other financial obligations with the next 5 years, such as a new car, new baby, college expenses, change in work time, etc., or have you done any of these since obtaining financing with our team?

If we can help show you some ways of building wealth faster or becoming debt-free quicker, would you be interested?
—Please choose an option—YesNo

One a scale of 1-10 (10 being best) please rate your relationship with the following situations:
Real Estate Agent
Tax Preparer/CPA
Financial Planning
Trust and/or Will
Life Insurance
Auto and Home Insurance

Who do you know that might benefit from our services?