Borrower Information Form


(*) Required Fields
State:
Home Description:	*
	If Other Then Specify:
Credit Profile:
Purpose of Loan:	*
	If Other Then Specify:
Purchase Year:	*
Home Value :	$ * (e.g.123456)
1st Mortgage Balance :	$ * (e.g.123456)
1st Mortgage Interest Rate :	% * (e.g.12)
Existing type of Rate:
Do you have a second mortgage?	YesNo *
How much cash do you want to borrow?	$ * (e.g.123456)
Gross Annual Income:
Occupational Status :
Have you filed for bankruptcy in the last 7 years?	YesNo *
Screen Name:	* (Brokers will see this Screen Name, not your e-mail address)
Referral Code:	(If Any)
Email Address:	* (This is your login ID)
Password:	* (Password should be 6 to 15 characters)
Retype Password:	*