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| Q. | Do you have a house to sell? |
| A. | Yes No |
| Q. | Will you need a mortgage? |
| A. | Yes No |
| Q. | Will you need home owners insurance? |
| A. | Yes No |
| Q. | You give us permission to assist you and contact you if needed? |
| A. | Yes No |
| Q. | Are you working with another agent? On the buying side, selling side or both? |
| A. | Yes No |
| Your name | |
| Phone No | |
| Address | |
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