Contact Information
   Type of Information Requested:               
  Loan Purpose:                                       
  Your full legal first name:                             
  What is the name you normally use?      
   Your middle initial:                                 
  Your last name:                                       
   Marital Status:                                         
  Date of Birth:                                           

  Work Phone:                                               Ext. 
  Home Phone:                                          
  Cell Phone:                                              
  Fax:                                                          
  Email:                                                       

  Current Address

   Address   
  City              State       Zip  

  Home Purchase Information (Only if you are interested in a Home Purchase Only!)

  Have you already been pre-qualified?  
  Are you currently in contract?                
  What is your target purchase price?      
  How much do you have saved
  for a down payment?                            
  Time frame to buy?                                 

  Home Refinance Information (Only if you are interested in a Home Refinance Only!)

  What is the current estimated
  Value of your home?                               
  Will you be occupying the home?          
  Will this be a second home?                   
  Current 1st Mortgage Balance                
  Current 2nd Mortgage Balance              
  Other Liens (Tax, Mortgage, Etc.)            

  Required Information

  Do you have credit problems?   
  Your Verifiable Income:               
  (Before Taxes)

   Other Borrower Verifiable            
  Income:(Before Taxes)
  Credit Card Payments:                 Per Month.
   Auto Payments:                             Per Month.
  Loan Product Desired?               
  Best Time to Call You!                 
  How did you hear about us?     
  What Keywords did you use to find us?         

  What Search Engine did you use to find us?   (Yahoo, Google, MSN, etc...)

  Please use the space below to describe your financing needs,
  reason for credit problems or to request specific information.
  Please be open about your situation as this is important in us being able to help you:
 

Thank you!
You will be contacted shortly or by next business day!
         

SECURE QUICK LOAN APPLICATION

 For Your Protection and Comfort, We Do Not Require
Your Social Security Number Here. One of Our Representatives Will Retrieve That Information From You Personally!

Complete this form and submit below to get started today.
 Unfortunately we do not lend in the following states:
 New York, Kansas, New Jersey and West Virginia.
We can only lend 2nd mortgages and equity lines in Ohio.