Nurse/Healthcare Worker Questionnaire Form

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Nurse/Healthcare Worker Questionnaire Form

Nurse/Healthcare Worker Questionnaire Form

Thank you for your interest in home-buying assistance for Nurses & Healthcare Workers. This is a complimentary service provided by Rx Realty, a Nurse-Owned company, in partnership with Nightingale Benefits. By answering the following questions, you are expressing an interest in receiving more information about our home-buyer assistance service.

16Questions

1
Your Name* This field is required.
First Name
Last Name
2
What is your current job title?
3
Is this a Travel Agency position?Please note that for Travel Positions, we will not be able to count your stipend or per diem pay towards your income.
YESNO
4
What state are you hoping to buy a home in?* This field is required.
Please Select
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
5
What City or Area?
6
Are you currently working with a real estate salesperson or Realtor?* This field is required.*If you are already working with a Realtor, you may not qualify for most of our program options.
YESNO
7
Number of people in your household?Including yourself.
8
Will someone else be qualifying for a home loan with you?Answer 'yes' if you have a significant other or family member going on the home loan with you.
YESNO
9
If you had to guess what your credit score was, where would you say it's at today?* This field is required.Your best guess will do. We'll verify your true credit score down the line.
520-580
580-680
700+
under 500
10
Current yearly household income:* This field is required.For all of you hard-working people, you may include over-time if it has remained steady over the past 2 years.
11
Have you filed for bankruptcy in the last 3 years?* This field is required.We can discuss options if you have.
YESNO
12
Have you foreclosed on real estate property in the last 3 years?* This field is required.
YESNO
13
How soon do you want to purchase a home?No pressure...just want to make sure we are working within your time line.
As soon as possible.
3 - 6 months
6 - 12 months
Not sure.
14
Do you have funds saved up for either a down payment or closing costs?We can let you know how much you might need to save, but we will have most, if not all of your closing costs covered.
YESNO
15
Email* This field is required.You may receive periodic, reminder emails from Rx Realty, Nightingale Benefits and your local real estate specialist.
example@example.com
16
Phone Number* This field is required.We cannot help you if we cannot reach you. Valid numbers only please.
Area Code
Phone Number
Should be Empty:

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