Borrower1:  S.S# D.O.B.

Borrower2:  S.S# D.O.B.

Address: Country:

City: State: Zip:

Home Phone: ()-  Work Phone: ()-

What is the best time to reach you?

REASON FOR LOAN:  Consolidate Bills Lower Rate   Purchase

Amount Wanted:

Credit History:    Excellent   Good   Fair   Poor

PROPERTY

VALUE OF HOME:   LAST TIME APPRAISED:

TYPE:    Single Family   Duplex   Modular/Mobile   Sq. Footage:

When Purchased:   Purchase Price:

Number of years in home:

MORTGAGES

First Mortgage:   Balance:

        PMT:   Rate:

Second Mortgage:   Balance:

        PMT:   Rate:

INCOME

Borrower1 Employer:   Position:

    Time on job:   Time in industry:   Annual Income:

Borrower2 Employer:   Position:

    Time on job:  Time in industry:   Annual Income: