Independent Mortgage
Quick Application
Date: Select Date Referred by:
Borrower Information: Co-Borrower Information:
Full (Legal) Name: Full (Legal) Name:
Current address: Current address:
City:       State:       Zip Code: City:       State:       Zip Code:
Time at current address: to: Present Time at current address: to: Present
Own or Rent: (If renting, rent amount? ) Own or Rent: (If renting, rent amount? )
Previous addresses/dates (if less than 2 yrs @current address, Include Zip Code): Previous addresses/dates (if less than 2 yrs @current address, Include Zip Code):
Date of Birth: Select Date Date of Birth: Select Date
Social Sec #: Social Sec #:
Home phone#:       Cell#(if different): Home phone#:       Cell#(if different):
Email Address: Email Address:
Borrower Employment/Income Information: Co-Borrower Employment/Income Information:
Current Employer: Current Employer:
Dates @current employer: to Present Dates Dates @current employer: to Present Dates
Job title:       Work #: Job title:       Work #:
Gross income:       If hourly, #hrs per wk Gross income:       If hourly, #hrs per wk
Bonus/Commission?       Self employed?** Bonus/Commission?       Self employed?**
Previous/2nd employer #1: Previous/2nd employer #1:
Dates @previous/2nd employer: to Dates @previous/2nd employer: to
Previous/2nd employer #2: Previous/2nd employer #2:
Need a full 2 year employment history, if there was a job gap of over 6 months, please list history prior to gap. (if in school, list dates & degree if applicable) Need a full 2 year employment history, if there was a job gap of over 6 months, please list history prior to gap. (if in school, list dates & degree if applicable)
Any other income you would like considered? (i.e., child support, alimony, trust, etc?: Any other income you would like considered? (i.e., child support, alimony, trust, etc?:
Need a full 2 year employment history, if there was a job gap of over 6 months, please list history prior to gap. (if in school, list dates & degree if applicable) Need a full 2 year employment history, if there was a job gap of over 6 months, please list history prior to gap. (if in school, list dates & degree if applicable)
**If self employed list NET self-employed income for last 2 yrs as shown on tax returns. **If self employed list NET self-employed income for last 2 yrs as shown on tax returns.
If own current residence:
Original purchase price:       Mortgage holder:       Mortgage Balance:       Interest rate:
Escrow account?       Yearly insurance premium:       Agent:       Total monthly payment:
Estimated value of house:       Type: (single family, condo, etc?)       Any other mortgages? (list balance & rate):
Requested Loan Amount:       Purpose:       Terms considered (Fixed/ARM/15, 20, 30yr):
Funds for downpayment & source, if applicable (checking/savings/retirement/investment/401k/gift/etc):
Do you have a price range (if purchase) or a payment range (purchase or refinance) in mind?  
Comments: (Credit history, questions, etc):

PLEASE SELECT: