On-Line
Loan Application
 
 
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Electronic Loan Application

Please identify yourself:

Borrower Co-Borrower
Nickname Nickname
First Name  First Name 
Middle Initial  Middle Initial
Last Name Last Name
Date of Birth Date of Birth
Social Security Social Security

Where do you presently live?:

Street Address
City
State
Zip Code
How Long Have You Lived Here?
Do You Own or Rent
Who is your Landlord or Mtg. Co.?
What Are Your Monthly Payments?

Where do you presently work?:

Borrower's Employment Information
Current Employer's Name
Employer's Address
Employer's Telephone
How Long Have You Worked Here?  Years on the job.
What Are Your Hourly Wage?  Wages per hour.
OR, Are You Paid A Fixed Salary?  Yes or No
If Salaried, What is Your Monthly Salary?  Gross Monthly Salary
How Many Hours Per Work Week? Hours per week.
Any Other Source of Income (describe)?:

 

Co-Borrower's Employment Information
Current Employer's Name
Employer's Address
Employer's Telephone
How Long Have You Worked Here?  Years on the job.
What Are Your Hourly Wage?  Wages per hour.
OR, Are You Paid A Fixed Salary?  Yes or No
If Salaried, What is Your Monthly Salary?  Gross Monthly Salary
How Many Hours Per Work Week? Hours per week.
Any Other Source of Income (describe)?:

How can we contact you?

Home Phone
Best Time to Reach You at Home?
Work Phone
Best Time to Reach You at Work?
Your E-mail Address
Comments?
How Did You Hear About Us?

To Find You The Best Loan, Please Answer A Few More Questions.

How Would You Rate Your Credit (Borrower)? 
How Would You Rate Your Credit (Co-Borrower)? 
What Amount Do You Wish To Invest In Buying A Home?
What Price Range of Home are You Thinking About?
How Do You Want Us to Confirm Receiving Your Application?

Please "Sign" Below and We'll Get Started.  

     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.
     This is an On-line form.  By typing my/our full name below, I/We hereby authorize this to be the same as my/our written signature (s).
On-line Signature: Borrower

PRINT YOUR FULL NAME HERE >

  

Date

On-line Signature: Co-Borrower

PRINT YOUR FULL NAME HERE >

  

Date

 

Copyright © 1999 [The Second Regency, Inc. and/or its assigns]. All rights reserved.
Revised: September 15, 2006