General information

Please provide the following contact information:

First Name	Borrower                               Co-Borrower
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
	Rent?  Own?     # of years: If owned, value:
	If owned, type: Single Family Home - Condominium - Townhouse - Multi Family - Co-op - Other
	Is this property your: Primary Home Investment or 2nd Home
Work Phone
Home Phone
FAX
E-mail

Are you self-employed?     Borrower  No Yes Co-Borrower No Yes

Gross Monthly Income - Borrower     
Gross Monthly Income - Co-Borrower 
Date of Birth - Borrower Date of Birth - Co-Borrower

Loan Information

Amount Requested:    Current 1st Mortgage Balance:

How do you rate your credit?* Excellent Good Average Poor

Type of Loan Requested:
Select any of the following options that apply:

Purchase            Refinance           2nd Mortgage        Equity Loan       
Home Improvement    Debt Consolidation  

How did you hear about us? Yellow Pages Search Engine 
  Referred by a Friend  Letter Mail  Fax
 			

Purpose of Loan

Please tell us the purpose of your loan in the area provided below.

Verify. Enter the numbers you see into the blank field on the right. Why we do this.