Name:

Company:

Address: City:

Province/State: Postal Code:

Company GST # (Canada) or Federal Tax # (USA):

E-mail:

Telephone: Fax:

CLIENT

Name:

Company:

Office Address:

City/Prov: Postal Code:

Home Address:

City/Prov: Postal Code:

Best Time To Call at Office: Phone:

Best Time To Call at Home: Phone:

Call As Soon As Possible Yes No

If Not, When and Why?

Lou will send immediate confirmation of acceptance of this referral.

Thank You.

* Not intended to solicit properties already listed.