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Are you a current homeowner ? Yes, No
Applicant Information
Loan Amount Requested*		Purpose of Loan
Applicant		Co-Applicant
First Name*		First Name*
Last Name*	Age	Last Name*
Social Security Number: - -		Social Security Number: - -
Home phone		Home phone
Work phone		Work phone
Property Information
Owner Occupied, Vacation Home, Investment Property
Subject Address
Street		State
City		Zip Code
Names on Deed
.Yearly Taxes ($)		Insurance ($)
Refinancing
Orig. Purchase Date		Orig. Purchase Price ($)
Present Market Value ($)
1st Mortgage Balance ($)		2nd Mortgage Balance ($)
1st Mortgage Holder	Interest Rate (%)	2nd Mortgage Holder	Interest Rate (%)
Current Payment ($)	Years Remaining:	Current Payment ($)	Years Remaining:
Include Taxes and insurance ? Yes No		Include Taxes and insurance ? Yes No
Purchases
Have you found the particular home you want to purchase ? Yes No
Purchase Price: ($)		Down payment: ($)
Are you in Contract?: Yes No		Estimated Closing Date:
Source of Funds:		Seller Concession: (%)
Applicant Employer		Co- Applicant Employer
Name:		Name:
Phone:		Phone
Income Annual ($):		Income Annual ($):
Self Employed ?		Self Employed ?
Position:	Years:	Position:	Years:
Additional Income ($):		Additional Income ($):
Other
E-Mail:		Best time to call:
How did you find our site?		How would you rate your credit?:
Do you know your credit score?:		How would you rate your mortgage/rental history:
Comments:

* I/We hereby give our consent to Eastland Mortgage, and any credit reporting bureau designated by Eastland Mortgage, to obtain any and all information concerning our employment, checking and/or savings account, obligations and all other credit matters which they may require in connection with our application for a mortgage loan. This form may be reproduced or photocopied and a copy shall be as effective consent as the original which we have submitted.