Customer Intake Form First Name Address Zip Code Work Phone Race African AmericanCauscasianHispanicAsianAmerican IndianOther Current Housing Situation RentHomeowner with MortgageHomeowner/Mortgage PaidLiving with Family Member No Rent Are you currently working with a Real Estate Agent YesNo Are you a Veteran? YesNo Middle City Home Phone Your email Marital Status SingleMarriedDivorcedSeparatedWidow Household Type Single AdultMarried AdultTwo or More Unrelated AdultsOther Agent Name & Phone Name & Phone Have you owned a Home in the last (3) years? YesNo Last Name State Cell Phone Date of Birth Gender MaleFemale Do you have a contract on a house at this time? YesNo Do you have a pre-approval from a lender YesNo How Did You Hear About Us? InternetPrint AdvertisementBankGovernmentTVRadioRealtorStaffFriendWalk In Authorization I authorize the Housing Counseling Agency to: (a) I understand that I am under no obligalion to use any or lite presenters at this workshop (b)Obtain a copy of the HUD-1 Settlement Statement, or Closing Disclosure when I purchase a home, from the lender who made me/us a loan and/or the title company that closed the loan. (c)"I" Understand that workshop is free of charge. "I/We understand that any Intentional or negligent representation(s) of the information contained on this form may result in civil liability under the provision of Title 18. United State Code, Section 1001." ACCEPT 0TEAM MEMBERS0INDUSTRY AWARDS0HAPPY CUSTOMERS0%SATISFACTION
