Exchange America's One-Time Contact Form

Welcome to our FREE Registration area.

Please complete this one-time contact form

Upon submission, you may immediately...
1) enter haves/wants in our unique Meet-Your-Match Database and 2) request contact with our advertisers.
3) receive users' "broadcast" have/want information free, by email. Receive by fax or snail mail for $25/6 months.
4) Place a low-cost ad ($12-$95)

Once you've submitted your contact information on this or any of our request forms, it'll only be necessary to
enter your name & email address or your name & phone #, when making requests on any of our forms in the future.

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Please call us at 1-800-982-3716 and leave a message or call us directly at 970-375-7112, if you have questions or problems filling out this form.

Please complete every applicable blank. Required information will be indicated by the * symbol...

Private Individuals, please complete section #1 & section #2, if you're working with a broker. Brokers, please complete section #2.

**Private Individuals**
* Your Name
Company
* Day Phone	and/or enter your email address, below
Evening Phone
Fax

Your Mailing Address

Street or P.O. Box Address
City	State	Zip
* E-mail Address

*Are you a(n):

Broker Agent Private Party Developer Investor Vacationer
If you're a Private Party, are you listed with an Broker/Agent? Yes No
If you're a broker or are the client of a broker, please answer the following questions. If you're a private individual without a broker, push HERE to skip to the next section:

Broker/Agent Information

Broker or Agent Name
Company Name
Address

Day Phone
Evening Phone	(Optional)

If you know it, please enter your Agent or Broker's:

Fax

E-mail Address

How would you prefer that customers contact you?

* 1st Choice:

Phone	FAX	If applicable:	no earlier than
E-mail	Regular Mail		no later than

2nd Choice:

Phone	FAX	If applicable:	no earlier than
E-mail	Regular Mail		no later than

Referral Information (optional, but appreciated)

How did you find us?
If you heard about us from another source, where/who?

Submit your Registration

If you're done filling out this form, submit it by pushing the button below:

You will receive an automated response and the opportunity to register Real Estate, Investment, Business, Vacation or Related Opportunities.
You may also request free contact with any of our current advertisers or take advantage of our low-cost services.

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