This form may be used for prequalification or application for any of our programs. There is no cost or obligation to submit your information. A mortgage loan origionator will contact you with options and to see if you wish to proceed further. We have a strict privacy policy and your data will not be used for marketing or any other purpose. If you do not have all the information or are not sure about something just skip that part and we will get it later.

Borrower		Co-Borrower (if applicable)
Name		Name
Address		Address
City		City
State, Zip	,	State, Zip	,
How long at this address?	Years	How long at this address?	Years
Renting or Buying?	Renting  Buying	Renting or Buying?	Renting  Buying
Current Payment	per month	Current Payment	per month
Date of Birth	Month January February March April May June July August September October November December ,   Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,   Year 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000	Date of Birth	Month January February March April May June July August September October November December ,   Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,     Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Social Security Number		Social Security Number
Home Phone		Home Phone
Cell Phone		Cell Phone
Work Phone		Work Phone
Best Contact	Choose One Home Cell Work	Best Contact	Choose One Home Cell Work
Email		Email
Employer		Employer
Job Title		Job Title
Monthly Gross Income	per month	Monthly Gross Income	per month
How Long at Job	Years	How Long at Job	Years
Other Income Amount	per month	Other Income Amount	per month

Property to Purchase (TBD if still looking)
Address
City, State & Zip		,
Purchase Price or Price Range
Is there a specific loan program you prefer?
Do you prefer a fixed or variable rate?		Fixed  Variable
Do we have permission to get a credit report for you (no charge)?		Yes, I grant permission for you to obtain my credit report.
	Other Comments