1.    Borrower's first name:

2.    Borrower's last name:

3.    Borrower's address:

3.    Age:

4.    Marital status: Married  Single

5.    Present Employer:

6.    How long have you been employed at 

      your present job?

7.    Yearly salary?

8.    If employed less than 2 years, list your 

      previous employer:

9.    Presently, do you own or rent your home?

10.    If you do not own, give name of landlord:           

11.    Amount of monthly rent:

12.    If you own your home, is your home paid for?     

13a.    If "no" to Q.12, which company carries your   mortgage?        

13b.    What is your mortgage balance?

13c.    What is your mortgage payment?

14.      List your present creditors and your outstanding balances:

               Creditors                                         Balances

1.    $

2.  $ 

3.  $ 

4.  $ 

5.  $ 

15.    List your assets (fill in amounts):

        a.    Cash on deposits:  $

        b.    Automobiles:  $

        c.    Stocks and bonds:    $

        d.    Life insurance:    $

        e.    Real Estate:    $

        f.    Other assets:    

P.S. If there is a co-borrower, please fill out the same questions for the co-borrower by resending this application form with the co-borrower's information.

        Please enter any additional information if needed:

Tell us how to get in touch with you:

Name
E-mail
Tel
FAX

Please contact me as soon as possible regarding this matter.