What type of home are you looking to purchase (select one)?

Single Family
Townhome
Condominuim
Other (please specify)

What is the price of the home you're buying?

Will this be your primary residence? Yes  No

Will you be selling a home to purchase this one? Yes  No

How much are you expecting for your down payment?

What is your approx. annual household income?

Are you a first time home buyer? Yes  No

Do you have any special credit considerations (select one)?
No, I have excellent credit
I have little to no credit
Yes - I have specific issues I need to discuss
Possibly, but I don't know

Please list any other specific issues that may effect your qualification for a home loan (personal/business liabilities and assets, alimony or other income, conversion, etc).

Your Name

Address

Address (cont'd)

City   State    Zip

Daytime Phone

Evening Phone

Email