Contact Information

First name: Last name:

Home phone/Area code: Number:

Cell phone/Area code: Number:

Email address:

Mailing/Street address: Unit #:  

City: State: Zip code:

Personal Information

How much money on hand do you have to work with?  

Source of down: Savings     401k     Family/friends     Don't have down, but have excellent credit and income.

Primary Borrower:

Occupation/Job: No. of years:

Monthly Income:        Self employed: Yes No

How is your credit? Excellent   Average     Poor  - Score:

Have you ever filed bankruptcy? Yes No  -  If so, when:

Marital status: Single Married 

Secondary Borrower:

Occupation/Job: No. of years:

Monthly Income:        Self employed: Yes No

How is your credit? Excellent   Average     Poor  - Score:

Have you ever filed bankruptcy? Yes No  -  If so, when:

Marital status: Single Married 

Property Information

Refinance property/address: Same as above     (If different fill out address below.)

Refinance property/Street address:  

Unit #:  

City: State: Zip code:

How much can you pay/current payment per mo.?    First time buyer: Yes No 

What type of property do you want/have?

Condo     Townhouse     Single Family     Land     Commercial

 #/Bedrooms:      #/bathrooms:     Sqft:     

Pool     Spa    Other:  

 Zoning/Land & Commercial only:  

If buying, what location are you looking for? 

City:   State:   Area:

Can you tell us more?

Do you need to sell your property before buying? Yes No 

When are you ready to refinance/buy?

Now        30 days        90 days        6 months        1 year

What questions do you have?

Brief survey

How did you hear about us? Internet TV/cable Newspaper  Homes

& Land Magazine Yard sign  Bus bench    US mail  Email message 

Past client        Other: