What text fields to include in motivated sellers form?

[Daniel Featherston]

Experienced wholesalers who utilize websites, 

What fields, drop-downs, and/or check boxes do you include in your motivated sellers form?

Basic info:
First Name, Last Name, Email, Phone, Address, City, State, Zip

Qualifiers/Probing:

Property Type, Bedrooms, Bathrooms, Asking Price, Lowest Price, Listed With Agent Check-box, Is House Occupied Check-box, Reason Your Selling Text Input Field

This is what I've put together so far. Am I missing anything?