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Broker Referral

Broker Information:
 Office/Company Name: 
 Broker Name: 
 Relocation/Director Name: 
 Referring Agent Name: 
 Address: 
 City: 
 State: 
 Zip: 
 Fax: 
 Phone: 
 Email: 
Would you like to request a specific agent?
Yes No
 Name of Agent: 
Client Information:
 Client Name: 
 Address: 
 City: 
 State: 
 Zip: 
 Phone: 
 Email: 
Buyer Information:
 Destination City:
Cities We Service 
 Employer: 
Transfer?
Yes No
Currently Owns?
Yes No
Currently Rents?
Yes No
 Price Range: 
Pre-Qualified?
Yes No
 Amount: 
Housing Requirements:
 Bedrooms: 
 Bathrooms: 
 Garage: 
 Square Feet: 
Condition:
Older Newer
Children?
Yes No
School Info Needed?
Yes No
Relocation Kit Needed?
Yes No
 House Hunting Date: 
Seller Information:
 Address of Property: 
Tenants?
Yes No
 Tenant Name: 
 Tenant Phone: 
Currently Listed?
Yes No
Corporate Transfer?
Yes No
 Additional Contacts: 
 Reason for Selling: 
 Special Features: 
Is client aware they are being referred?
Yes No
Referral Fee Requested:
20% 25%
Other
Enter Any Comments or Questions Below:
 
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