Borrower

First Name                                  Last Name                            

Address                                             City                                                   State

Daytime Phone                          Evening Phone                  

Best time to reach you              Email Address                  

Amount of mortgage?              Term of mortgage?           10 15 20 25 30 Years

Occupation?                                      Date of Birth?                    

Height                                                                                Weight                                 

Do you smoke?                                                 Yes No       

Do you have diabetes?                                   Yes No

Have you ever had a heart attack?             Yes No

Have you ever had cancer?                          Yes No          

Have you ever had a stroke?                        Yes No

Co-Borrower

First Name                                  Last Name                            

Address                                             City                                                   State

Daytime Phone                          Evening Phone                  

Best time to reach you              Email Address                  

Amount of mortgage?              Term of mortgage?           10 15 20 25 30 Years

Occupation?                                      Date of Birth?                    

Height                                                                                Weight                                 

Do you smoke?                                                 Yes No       

Do you have diabetes?                                   Yes No

Have you ever had a heart attack?             Yes No

Have you ever had cancer?                          Yes No          

Have you ever had a stroke?                        Yes No