Contact Information
Name:
Home Phone:
Work Phone:
E-mail:
Best time to be reached:

Property Location
City:
State:

Personal Information
Annual Household Income is $

My Credit History Is
Excellent
Good, But Some Lates
Some Credit Problems
Major Credit Problems
Don't Know

Loan Amount
Loan amount desired is $

Type of Loan
30 yr fixed
15 yr fixed
30/5 yr fixed
30/7 yr fixed
Adjustable
Haven't decided
Other, Please State:

Type of loan
Credit Line
Fixed 2nd Mortgage
Other, Please State

Existing loans on property
1st Loan $
2nd Loan $

Do any of the loans have negative amortization?
Yes
No
Don't Know

Reason for loan
Home Improvement
Pay Off Bills
Other, Please Specify: