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Please complete the information below so we can better serve you. The information you provide will ensure that the right representative will contact you.

Name(s) :
Address :
City :	State :   Zip :
Home Phone :	Email :
His Work Phone :	Her Work Phone :
His Cell Phone :	Her Cell Phone :
Have you previously visited a Shriner Building Company Home? :	-- Select One -- Yes No
How did you hear about Shriner Building Company home? :	-- Select One -- Drive By Harmon Homes Website Radion DDN Referral TV(WHIO) Xenia Gazette
If someone referred you, who are they? :
Do you currently: . . . :	-- Select One-- Own Rent Home for sale Live with relatives/parents
Are You interested in building a new home? :	-- Select One -- Yes No
Do you currently . . . :	-- Slect One -- Own land Looking for land No land
Price Range :	$100-125K $125-150K $150-175K $175-200K $200-225K $225K +
Style of home your are interested in :	Ranch    Split level    2 story    Story and a half     Other
If Other, please describe :
When would you like to start building? :	-- Select One -- Now 6 months 12 months More than 12 months
Have you considered remodeling or adding on to your current home? :	-- Select One -- Yes No
Comment / Questions :
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