BHGRE - The Good Life Group - Submit Referral or Customer to Relocation

  • Submit a Referral
*This is:  
Member Number:  
*Customer Name:
*Pri First Nm: Sec First Nm:
*Pri Last Nm: Sec Last Nm:
Marital Status
Your Relation to Customer:
Has customer had prior contact with an agent?  
If yes, provide company name and agent name  
*Customer's Mailing Address:  
*Mailing Address City:  
*Mailing Address State:  
*Mailing Address Zip:  
*Mailing Address Country  
*Home Phone:  
Primary Work Phone:
Secondary Work Phone:
Primary Email:
Secondary Email:
Cell (primary):
Cell (secondary):
Best time to call:
Kids? Please describe.
*Confidential Referral?  
*Did you ask customer permission?  
*Type of Referral:      
Add'l Comments:
*Your Name:  
*Your Name:  
*Your Email:  
*Your Phone #:  
*Your Office:  
Broker Logo