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FAX
this completed form to US Home Price at (727) 467-0918
Please
print clearly to avoid a delay in processing. Instructions are
located
on the left.
A
minimum of 2 orders must accompany this registration.
Client
Information
First Name: ______________________ Last Name:______________________
Company (If self, please indicate):____________________________________
Phone: ________________________ Fax: ____________________________
Email Address:___________________________________________________
Credit Card Billing Information (Visa or MasterCard Only)
We
DO NOT
accept AMEX or Discover
Account Number: ________________________________________________
Expiration Date: _________________ (mm/yy)
Name on Account: _______________________________________________
Billing Address:__________________________________________________
City: ________________________ State: ______ Zip Code:
_____________
Service Agreement
I
hereby agree to only
request a US Home Price report as it pertains to fulfilling my obligations
as
a licensed real estate
professional, assessing the value of my home or the potential value of
investment
property I or my client may be interested in. In addition, I shall hold in the
strictest
confidence all information received
and will abide by all
applicable local, state and federal laws.
I
further agree to grant Federal Real Estate the right to charge my credit
card
for each report I
(or my authorized persons) submit.
Signature: __________________________________
Date:______________
Print Name: _________________________________
(cardholder signature required)
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