eReferral Form Member Name: * Your E-mail Address: * Your Day-time Phone: * Customer First Name: * Customer Last Name: * Spouse First Name: Spouse Last Name: Home Address 1: Home Address 2: City: State: Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Customer Phone Number Best Time for Broker to Contact Customer: How Do You Know this Customer? Type of Referral: Buying a New Property Listing a Current Property Both If listing, will the customer BUY ANY REAL ESTATE ANYWHERE in the country once sold? If buying, will they have anything to SELL ANYWHERE IN THE COUNTRY once they locate a new property? If Buying - What Area? If Listing - Enter Property Address: Does Customer know they are being referred? Customer knows they are being referred Customer does NOT know they are being referred Do you have a Broker Company preference? Do you have an Agent preference? Is the Customer already working with this Agent? Already working with agent NOT yet working with agent Does the agent know this lead is being placed with them as a REFERRAL? YES - agent is expecting the referral. NO - agent is not aware of the referral. Broker Office Phone: Does Agent already have customer's information? Agent already has customer information Agent does NOT have information on this customer Why Broker/Agent? Other Information?