| The Second Regency, Inc. 113 E. Albert Maize, KS 67101 | Application to Purchase | Telephone (316) 729-0001 Fax (316) 729-8332 |
| Use Your Browser Print Button to Print this Form. | ||
| PERSONAL INFORMATION | ||||
| Last Name | First Name | Initial | D.O.B. | Social Security Number |
| MARITAL STATUS: Married_____ Divorced _____ Single _____ | ||||
| CURRENT ADDRESS INFORMATION | |||||
| Present Address | City | State | Zip | Telephone | |
| Landlord & Their Address From To Telephone | |||||
| How have you made your rent payments? Cash_____ Money Orders_____ Checks_____ | |||||
| How many times have you been over 30 days late in the past two years? ____ Why?_____________________ | |||||
| PRIOR ADDRESS INFORMATION (If less than 3 Years at Current Address) | |||||
| Street Address | City | State | Zip | ||
| Landlord & Their Address From To Telephone | |||||
| Street Address | City | State | Zip | ||
| Landlord & Their Address From To Telephone | |||||
| Street Address | City | State | Zip | ||
| Landlord & Their Address From To Telephone | |||||
| BORROWER'S EMPLOYMENT INFORMATION | ||||||
| Current Employer's Name | Position | Supervisor | From | To | Salary | |
| Current Employer's Address Company Phone Your Work Phone | ||||||
| Previous Employer's Name & Address Phone# Position From To Salary | ||||||
| CO-BORROWER'S EMPLOYMENT INFORMATION | ||||||
| Current Employer's Name | Position | Supervisor | From | To | Salary | |
| Current Employer's Address Company Phone Your Work Phone | ||||||
| Previous Employer's Name & Address Phone# Position From To Salary | ||||||
| CREDIT INFORMATION |
| Have you ever filed Bankruptcy? Yes ____ No ____ If yes, when was it Discharged? __________________ |
| Do you have any Judgements? Yes ____ No ____ Any tax or other liens (medical)? Yes ____ No ____ |
| SETTLEMENT FUNDS |
| How much cash do you have to put into the purchase of a home? ____________________________________ |
| What is the source of these funds? _____________________________________________________________ |
| SIGNATURES | |
| I/We, authorize The Second Regency, Inc. and/or it's assigns to obtain a credit report of my/our credit | |
| history and hereby authorize the release of said credit report by any such credit reporting agency. | |
|
Borrower's Signature:____________________________________________ |
Date:_______________ |
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Borrower's Signature:____________________________________________ |
Date:_______________ |