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Name Daytime Phone

                                                                              Evening Phone

Current Address

Inspection Address

Property Description Select Single Family Home Town House Duplex Mobile Home Other   Number of Units 1 2 3 4 ? Number of Bedrooms 1 2 3 4 5 6 ?

Occupied Yes No ?      Utilities ON Yes No ?     Number of Baths 1 2 3 4 ?       Air Conditioning Yes No ?

 Your Real Estate Agent's Information