Cashback Rebate

Please fill out all the fields below in order for us to process your refund request.

Full Name

Your contact information and address which we will mail your refund to

Phone

Address

Please enter the information about the sale your are requesting a rebate for.

Agent Name

Sale Type

Enter the purchase price for the property you bought through an Agentscreener agent. If you did not purchase a property enter 0.

Purchase Price

Example: 250,000

Enter the sale price for the property you sold through an Agentscreener agent. If you did not sell a property enter 0.

Sale Price

Example: 250,000

Please enter the information about the sale your are requesting a rebate for.

Property Address

Close of Escrow Date

Example: 2/24/2009

Please describe your experice with the agent and Agentscreener.com

Comments

I certify that all of the above information is true and accurate to the best of my knowledge, that the purchase and or sale indicated above was done with the indicated agent, and that this agent was selected by me specifically though the use of the agentscreener.com website.

Clicking I accept means that you agree to the Agentscreener.com terms and conditions for this rebate.

CA Broker license # 01228252