Borrower Information: 

First Name:           Last Name:                SSN:    

Email:         Birthdate:  

Home Phone:        Bus Phone:        Cell Phone: 

Fax:        Contact Preference:  EMail Home Phone Bus Phone Cell Phone

  Co-Borrower Information: 

First Name:        Last Name:        SSN:    

Email:         Birthdate:  

Home Phone:        Bus Phone:        Cell Phone: 

Fax:        Contact Preference:  EMail Home Phone Bus Phone Cell Phone

  Present Address Information: 

 Street and Number:        City, State, Zip: 

  Subject Property Address:    (For purchase loan, if information known)

Street and Number:        City, State, Zip: 

  Employment Information: 

      BORROWER:    Self Employed:     Yes   No                 Monthly Income: 

                                    Years at current job:        Years in current line of work: 

                                    Please explain any other income:  

   CO-BORROWER:    Self Employed:     Yes   No                 Monthly Income: 

                                    Years at current job:        Years in current line of work: 

                                    Please explain any other income:  

  Mortgage/Property Information: 

PURPOSE:      Refinance:     Purchase:                   TYPE:  Residential:    Commercial: 

Property Type:  Single Family Home Condominium Townhome 2 - 4 Plex Commercial Building Mobile Home               Purchase Price: 

Appraised Value:        Loan Amount Desired:       

Mortgage Balance:  (If Refinance)         State Property is Located In: 

Property Financed Will Be:  Primary Residence Secondary Residence Investment Property Business

Additional Comments, Questions or Concerns: