| Are you a home
                              owner? 
 | Choose
                                one... Yes
                                No | 
                          
                            | Primary Applicant
                            Name: |  | 
                          
                            | Co-Applicant Name: |  | 
                          
                            | Street Address: |  | 
                          
                            | City: |  | 
                          
                            | State: |  | 
                          
                            | Zip Code: |  | 
                          
                            | Home Phone: | Example: (334) 123-4567
 | 
                          
                            | Work Phone: | Example: (342) 567-8901
 | 
                          
                            | Property Type: | Select your property...
                                Single
                                Family Residence Condominium Townhouse | 
                          
                            | Original Purchase
                              Price: | Example: 100K
 | 
                          
                            | Year Acquired: |  | 
                          
                            | Estimated Property
                              Value: (Must be at least $50K)
 |  | 
                          
                            | Amount Owed on 1st
                              Mortgage: |  | 
                          
                            | Current Interest Rate on
                              1st Mortgage:
 |  | 
                          
                            | Fixed Or
Adjustable? | Choose
                                one... Fixed Adjustable | 
                          
                            | Monthly Payment on 1st
                              Mortgage: |  | 
                          
                            | Amount Owed on 2nd
                              Mortgage: |  | 
                          
                            | Current Interest Rate on
                              2nd Mortgage:
 |  | 
                          
                            | Fixed or
Adjustable? | Choose
                                one... Fixed Adjustable | 
                          
                            | Monthly Payment on 2nd
                              Mortgage: |  | 
                          
                            | Current Employer: |  | 
                          
                            | Years With Current
                              Employer: |  | 
                          
                            | Gross Yearly
Income: | Example: 60K
 | 
                          
                            | How is your credit? | Make
                                your best guess... Excellent Good Fair Poor | 
                          
                            | Best Time To Contact
                              You: | Choose
                                one... Morning at Work
                                Afternoon at
                                Work Evening at Work
                                Morning at
                                Home Afternoon at
                                Home Evening at
                              Home | 
                          
                            | Type Of Loan
                            Desired: | Select a
                                loan... Second Mortgage
                                Debt
                                Consolidation Refinance Refinance with
                                Cash Out Home Equity
                                Line of Credit | 
                          
                            | Loan Amount
                              Desired: (Must be at least $30K)
 | Example: 80K
 | 
                          
                            | Your E-Mail
Address: | Must be in form: name@domain.com.
 Please
                              verify. Thanks!
 | 
                          
                            |  |  | 
                          
                            | Please verify your information - especially
                              your telephone numbers and e-mail address - before
                              pressing the button. | 
                          
                            |     | 
                          
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