1st Borrower's Information

1. Name

2. Email Address

4. Home Phone

6. Marital Status

7. Present Address

8. How Long?

9. Previous Address

10. How Long?

Employment

11. Name of Employer

12. Self Employed?

Yes No

13. Years on this job

14. Years in this field

15. Date of Hire

16. Position

17. Business Phone

18. Monthly Income

If Less than two years at current job, please fill out the following:

19. Previous Employer

20. Self Employed?

Yes No

21. Years on this job

22. Years in this field

23. Date of Hire

24. Position

25. Business Phone

2nd Borrower's Information

26. Name

27. Email Address

29. Home Phone

31. Marital Status

32. Present Address

33. How Long?

34. Previous Address

35. How Long?

Employment

36. Name of Employer

37. Self Employed?

Yes No

38. Years on this job

39. Years in this field

40. Date of Hire

41. Position

42. Business Phone

43. Monthly Income

If Less than two years at current job, please fill out the following:

44. Previous Employer

45. Self Employed?

Yes No

46. Years on this job

47. Years in this field

48. Date of Hire

49. Position

50. Business Phone

Combined Estimated Debt

51. Estimated Monthly Minimum Credit Card Payments

52. Child Support

53. Estimated Monthly Installment Loan Payments

54. Current Rent or Mortgage Payments

Combined Estimated Assets

55. Savings

56. Checking

57. Stocks/Mutual Funds

58. Gifts

59. 401K

60. Other

61. How much (approx) do you expect to net from the sale of your home?

Consent Agreement

Additional comments, questions or requests:

Have you ordered anything from us before, or attended a workshop or conference?

yes no