Contact Me by:	e-mail  phone  fax
*Name of borrower
*2nd borrower (if any)
Street Address
City, State, Zip
*E-Mail
Daytime Phone with Area Code
Home Phone with Area Code
City and State were loan is desired
*Check One	Purchase Refinance
Amount of Loan
Gross Monthly Income	$
Amount Available For Down Payment	$
S.S. Number of 1st borrower (optional)	(Required for Written Pre-Approval)
S.S. Number of 2nd Borrower (optional)	(Required for Written Pre-Approval)
How Would You Rate Your Credit? (check one)	1. Excellent
	2. Good 3. Fair 4. Poor
Other Comments