Name:
Address:
City:
State:
Zip:
E-mail Address:
Phone Include Area Code:
Price Range From - To:	under $100,000 Under $60,000 $60,000 - $80,000 $80,000 - $100,000 $100,000 - $150,000 $150,000 - $200,000 $200,000 - $250,000 $250,000 - $300,000 Over $300,000
Choose Area:	Beaver Dam Horicon Reeseville Mayville Lowell Juneau Randolph Iron Ridge Burnett Waupun Other Area If other specify here
Number of Bedrooms:
Number of Bathrooms:
Acreage:
Fireplace? Yes/No/Optional:
Perspective Move Date: