First Name: Middle Initial: Last Name:

Street Address: Apt #: City: State: Zip:

Home Phone: Work Phone: Cell Phone or Pager:

E-Mail Address: (No Earthlink, Mindspring or Comcast Email accounts)

Year home purchased: Employers' Name:

How's your credit? Excellent Good Average Fair Poor Are you self employed? Yes No

Home value: Amount currently owed:

Gross Monthly Income: Date of birth:

Loan Request

Purpose of loan:
Home Equity/ Debt Consolidation
Smart loan
Low Interest Refinance
Purchase Real Estate / 1st time buyers
Commercial property purchase
Commercial property Cash out
Jumbo loan
Other (please specify):

Property Loan Information

Current Interest Rate on 1st Mortgage: Monthly Payment (Total 1st & 2nd Mortgages): per month

How'd you find us? (TV, Search, etc.)