Centek - Capital Group

BORROWER:	CO-BORROWER (Optional):
Name*:	Name:
Address 1:	Address 1:
Address 2:	Address 2:
City:	City:

State:	State:
Zip Code:	Zip Code:
Social Sec. #:	Soc. Sec. #:
Home Phone:	Home Phone:
Email*:
Work Phone:	Work Phone:

Employer	Employer
Position:	Position:
Years Employed:	Years Employed:
Gross Monthly Income:	Gross Monthly Income:
Other Income:	Other Income:

			Payment	Balance
Checking/Savings:		Mortgage or Rent:
Stocks/Bonds:		Installment Loans:
IRA/401K/TSP:		Credit Cards:
Real Estate Value:		Car Loans:
Other Assets:		Alimony/Child-Support:
	.	Other Liabilities:

Please check one of the following to specify the number where you can be called with your results.
Call Work Number.
Call Home Number.

By checking the following boxes, I/We authorize Centek to order an in-file credit report at no cost. All information reviewed will be kept in confidence and used only for mortgage pre-qualification purposes. This is not an application for credit.

Borrower agrees to above terms.
Co-Borrower agrees to above terms.

Enter the code exactly as you see it in the image