Agent Referrals

AGENT REFERRAL FORM

Complete the following agent referral form and Richard Bergeron will handle your client professionally.

* Required Field

Client Information

* My client is a:

* Client Name:

* E-mail:

Address:

City:

Province/State:

Postal/Zip:

Country:

Phone:

Fax:

Schedule

Date of move:

Year:

Employer Relocation:

Yes No

Name of Employer:

Financing

Prequalified:

Yes No

Lender Name:

Other:

Amount:

Home needed to buy or sell

Additional Notes:

Client's preferred method to receive updates

Phone Fax Email Postal Service

Agent Information

* Sales Rep Name:

* Agency Name:

Agency branch or location:

E-mail Address:

Mailing Address:

City:

Telephone:

Pager:

Fax:

Cellular:

Agent's preferred method to receive updates

Phone Fax Email Postal Service

Richard Bergeron