Request

Client details:
Title
Last name in full *
Initials *
Address 1 *
Address 2
City/Town *
State/Province
Zip/Postal code *
Country *
Home phone no. *
Business phone no.
Mobile phone no.
Email address

Property details

Street / House No. *
Postal code *	City/Town *

State when purchasing

Purchase price
Owner's name
Phone number

If bought or sold through real estate agent

Agency name
Location
Phone number

Additional information

Appraisal purpose *

Mortgage maturity date

Mortgage lender

National Mortgage Guarantee (NHG)

Yes No

Inspect structural alterations

Yes No

Work description

Work being done	Cost

Additional comments

Urgent request?

Check this box if you want to make this an urgent request (this will cost an additional �50)

Structural survey necessary?

Check this box if you would like to be informed about structural surveys, without any obligations. A structural survey provides you with information on the structural state of the house and may be compulsory when applying for NHG.

Nederlandse versie