First Name:	MI:   Last Name:
Street:	Apt:
City:	State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA PR RI SC SD TN TX UT VT VA WA WV WI WY  Zip:
Home Phone:	Cell Phone:  Fax:
Email:
Confirm Email:
Do you:	Own Rent Live with Relatve or Friend   How long at this address:
Date of Birth:
Monthly Rent or Mortgage:
Employment Type:	Employed Homemaker Military Enlisted Military Officer Other Retired Self-Employed Student Unemployed with Income Unemployed with No Income Unknown
Employer Name:
Employer Street:	Suite or Unit:
Employer City:	Employer State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA PR RI SC SD TN TX UT VT VA WA WV WI WY  Employer Zip:
Employer Phone:
Job Title:	How long employed:
Monthly income before tax:	Other income amount: Source of other income:
How would you rate your credit:	Excellent Good Fair Poor
Type of loan desired:	New Used Refinance
Contact preference:	Home Phone Cell Email   Coapplicant:
Comments:	Additional questions or comments
In connection with your transaction we may require information about you as described in this notice, which we handle as stated in this notice. 1. We collect non public personal information about you from the following sources:   a. information we receive from you on applications or other forms.   b. information about you transaction with us; and   c. information we receive from a consumer reporting agency 2. We do not disclose, nor do we reserve the right to disclose, any non-public personal information about our customers, customers or former customers to anyone, except as permitted by law. 3. We may disclose non public personal information about you as a consumer, customer or former customer, to non affiliated third parties permitted by law. 4. We restrict access to non-public personal information about you to parties who need to know that information to provide products and or services to you. 5. We reserve the right to change or alter our privacy policies without notice.
I agree to the above terms