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Name*	Day Phone*	Evening Phone*
Email Address*	Street Address*
City*	County*
State*	Zip Code*

Social Security Number*	Gross Monthly Income*
Employer Name*
Employer Street Address*
City*	State*	Zip Code*
Down Payment Available*	How did you hear about us?

Co-Buyer Information
Name	Day Phone	Evening Phone
Email Address	Street Address
City	State	Zip Code

Social Security Number	Gross Monthly Income
Employer Name
Employer Street Address
City	State	Zip Code
BORROWER AUTHORIZATION Privacy Act Notice: This information is to be used by the agency collecting it or its assignees in determining whether you qualify as a prospective mortgagor under its programs. It will not be disclosed outside the agency except as required and permitted by law. The information requested in this form is authorized by title 38, Chapter 37 (if VA); by 12 USC Section 1701 et. seq. (if HUD/FHA); by 42 USC, Section 1452b (if HUD/CPD); and title 42 USC, 1471 et. seq. or 7 USC, 1921 etr. seq. (if USDA/FmHA). PART 2 - BORROWER AUTHORIZATION I hereby authorize the Lender/Broker to verify my past and present employment earnings record, bank accounts, stock holding, and any other asset balances that are needed to process my mortgage loan application. I further authorize the Lender/Broker to order a customer credit report to verify any other credit information, including past and present mortgage and landlord references. It is understood that typing my name below will serve as authorization, and a printed copy of this form will also serve as authorization. The information the Lender/Broker obtains is only to be used in processing of my application for a mortgage loan.
Borrower*	Co-Borrower
Date*	Date
Married Unmarried