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	Contact Information
	First Name*
	Last Name*
	Address*
	City*
	State*		-- select -- AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
	Zip*
	Daytime Phone*
	Email*
	Loan Property Information
	Loan Purpose*		-- select -- acquisition refinance construction other
	Desired Loan Amount*
	Property Type*		-- select -- Auto Services Bed & Breakfast Campground/RV Park Condo Conversions Investment Condos Convience Store With Gas Equipment Financing Gas Station Health Care Hotel/Motel Land Light Industrial Marina Mixed Use Marina With Gas Mobile Home Park Multi-Family(2-4 Units) Multi_Family (5+ Units) Office Office Condo Restaurant Retail Rooming House Self Storage Single Family Residence Townhome/Residential Warehouse Working Capital Other
	If other please describe.
	Occupancy*		-- select -- Owner Occupied Investor
	Number of Units*
	Estimated Property Value*