Northside Mortgage of Southwest Georgia

Please fill out the form below completely and accurately and we'll have a loan officer contact you.
Purchase	Refinance		Second Mortgage
Amount Of Home:
Marital Status:		Married Single
First Name:
Last Name:
Spouses First Name:
Spouses Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Spouses' Work Phone:
Fax Number:
Email Address:
Social Security number:
Spouses Social Security Number:
Fair Market Value:
First Mortgage Balance:
Second Mortgage Balance:
Credit History:
Excellent	Good	Fair	Poor
Is your mortgage payment current now?		Yes No
How many times have late in last year?
Self Employed?		Yes No
Employer
How Long?
Income:
Income Type:		Salary Commission
Spouse Self Employed?		Yes No
Employer:
How Long?
Income:
Income Type:		Salary Commission
Additional Income:
Questions and Comments:

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		Albany Northside Mortgage Inc., d/b/a Northside Mortgage Georgia Lender License # 12844 1201 Dawson Road Albany, Ga 31701 229-878-1499 • info@albanynorthside.com Mortgage Bankers Georgia Residential Mortgage Licensee