First Name   Last Name

Address     City   State    Zip

Home Phone      Business Phone     E-mail Address 

Your Employer      How Long  

Spouse's Name      Spouse's Employer 

Are you Military?     If Military, Rank      Unit Address 

Special needs     

Bedrooms  2 bedrooms 3 bedrooms 4 bedrooms 5 bedrooms 6 bedrooms     Baths  1 2 3 4     Livings Areas  1 2 3    

Dining Areas  1 2     Garage  Two car One car Doesn't matter No

Are you familiar with Fort Hood area? Yes   No Desired Home Location Copperas Cove Killeen Harker Heights Other    

If other location is desired, where? 

Do you have children?  Yes    No Names and ages of children 

Price range desired: 40-50 K 50-60 K 60-70 K 70-80 K 90-100 K 100-125 K 125-150 K 150 + K   Amount of down payment available:  Desired monthly payment:

Type of financing desired: Conventional     VA

Do you currently: Rent     Own      Do you have VA eligibility?  Yes    No

Address and phone number while on leave:

Check box if you would you like a relocation packet:

Additional comments: