Needs Assessment Form

 

 

CONTACT: Gerry Dysart

Address: Prudential Gary Greene Relocation Department

10575 Katy Freeway, Suite 100

Houston, Texas 77024

Telephone (713) 465-6644

Fax (713) 465-9823

E-Mail: GDysart@GaryGreene.com

 

Customer Information

 

Company Name:   ClientCompany

Mr.  Mrs.  Ms.

Last/ Family Name: Phone (Work)

First/Given Name Phone (Home)
Date of Birth Phone (Mobile)
Nationality: Fax (work)
Citizenship: Work Email
Employee ID Number Personal Email
Languages Spoken: Social Security #

PRESENT HOME ADDRESS

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

DESTINATION

City:  
Country:  
Office:  

Office Address:

 
Length of Assignment:  
New Position/Title:  
Expected Move Date:  
   
Family Data

Mr.  Mrs.  Ms.         Spouse      Companion

Last/Family Name:

First/Given Name:

Date of Birth:

Nationality:

Languages:

Additional Adults:

CHILDREN

  Child #1 Child #2 Child #3
Last/Family Name:  
First/Given Name:  
Sex:       Male   Female   Male   Female Male   Female
Date of Birth:  
Nationality:  
Languages:  

          LIST ADDITIONAL CHILDREN BELOW

FAMILY or PERSONAL HOBBIES, INTERESTS:

Pets (Please list any pets- include breeds, weights and descriptions if dogs or cats)

ANY PERSONAL CONCERNS?

Destination Services

FLIGHT INFORMATION (IF APPLICABLE)

Is transportation at the airport required?  Yes  No

Airport:  Departing From:
Airline:  Date of Arrival:
Flight #: Time of Arrival:

TRANSPORTATION NEEDS

Do you plan on purchasing or leasing a car upon US arrival?      Purchase Lease


PRESENT ACCOMMODATIONS

Text Box: For Rental Properties Only:
 Need Pets Allowed
 Need Smoking Allowed
City      Suburb       Rural
House  Apartment  Garden

Number of Bedrooms  


ACCOMMODATIONS NEEDED:

Buying Renting  
Furnished     Unfurnished  
House Apartment/Condominium  
City   Suburb  
New Development  Older Development  
Rural Garden  
       # of Bedrooms          # of Bathrooms:  

 

Preferred Areas/Neighborhoods:

Maximum Commute Time Preferred:

Is Proximity to Shopping Areas Important?   Yes   No

Is Proximity to Schools Important? 

Yes    No
Is Proximity to Public Transportation Important? Yes   No
Is Proximity to Community or Sporting Facilities Important? Yes   No

 

 

Additional Accommodation Comments:


Please add any additional comments or requests below:

         

Submit Form changes to jgclark@garygreene.com.
Copyright 2005 Prudential Gary Greene, Realtors. All rights reserved.
Revised: 11/10/05