Name:   
Address:
C/S/Z:   
Phone:  
Mobile:  
Email:    
1st time home buyer: YES     No
Reason for Loan: Purchase Refinance Debt Consolidation Construction Investment Lot/Land Other
What term are you interested in (Check all that apply):
10 year fixed           15 year fixed           20 year fixed
25 year fixed           30 year fixed           40 year fixed
       1/1 ARM                   5/1 ARM                   7/1 ARM  
Please estimate your credit score: Excellent Good Fair Poor Don't Know
Have you ever declared Bankruptcy? No Yes
Have you ever had a property foreclosed upon? No Yes
Will you have a co-borrower? Yes No
Co-borrower Name:
Monthly Income:
Loan amount:
House Value: 
Purchase price (if purchase):
Type of property: Single Family Detached Single Family Attached Condo Modular/Manufactured Multi-Unit Unknown Investment
Are you working with a Realtor? No Yes N/A
Best time to contact you: Morning Afternoon Evening Any