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.