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First Name
Last Name
Email
Phone #
Address
City
State
Zip Code
SS#
Re-Enter SS#
Birthday
Citizenship Status
Choose an option
US Citizen
Permanent Resident
Non-Permanent Resident
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Preferred Contact Method
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Email
Phone
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Occupancy Status
Choose an option
Own w/Mortgage
Own Free & Clear
Other
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Occupancy Duration -YEARS
Choose an option
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25-30
31-35
35-50
50+
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Occupancy Duration - MONTHS
Choose an option
0
1
2
3
4
5
6
7
8
9
10
11
12
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Gross Monthly Income (before taxes)
Monthly Mortgage/rent payment
Employment Status
Choose an option
Employed
Self Employed
Unemployed
Retired
Active Military
Retired MIlitary
Homemaker
Student
Government/DOD
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Job Title (Former Job title if retired)
Employer (Former Employer if Retired)
Years at job (If retired, Years Retired)
Choose an option
Less than 1
1
2
3
4
5
6
7
8
9
10
11-15
16-20
21-25
26+
Item 7
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Requested Loan Amount
Are you willing to setup this loan on automatic payment for a reduced loan rate?
Choose an option
Yes
No
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If needed, you will be able to add
a co-applicant on the next page.
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