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To Pre-Qualify for a loan, simply follow these steps:

  • Fill in the appropriate fields.
  • Click the "SUBMIT" button, located at the bottom of this form.
  • Once your form is submitted, you will receive a confirmation notice stating that your form was successfully received. One of our brokers will contact you within 24-hours with a notification of your loan pre-approval.

    THIS PAGE AND THE INFORMATION CONATINED WITHIN IT ARE SECURE.

These Questions Apply To The Borrower
Your Full Name:
Your Spouse Full Name:
Your Age:
 Date of Birth: (mm/dd/yyyy)
Your Spouse Age:
 Spouse Date of Birth: (mm/dd/yyyy)
E-mail Address:
Street Address:
City:
State:
Zip Code:
Form of Residence:
 Own Rent Monthly Rent/Mortgage$
No. of Years:
Previous Address:
City:
State:
Zip Code:
 Years Lived There
Marital Status:
 Married Separated Unmarried (Single, Divorced, Widowed)
No. of Dependents:
Dependents Ages :
Price Range of house do you want:
 $
How much cash to you have to work with
(including closing costs and down payment?):
 $
Do you pay child support, amount paid monthly:
 $
Are you a United States citizen?
 Yes No
Have you filed bankruptcy before, if so when was bankruptcy dischared by court date & Year:
Are there any tax lien against you?:
Are there any judgement against you?:
Are there any repossessions against you?:
Have you ever defaulted on a federal debt before:
Your Social Security:
Your Spouse's Social Security:
Daytime Phone:
Evening Phone:
Cell Phone :
Best Time to Call:
Self Employed:
 Yes No
Name of Your Company or Your Employer:
Company Address :
Work Phone:
Occupation:
Length of Time on Job:
 (Years)
Your Monthly Gross Income:
 ($)
Your Spouse's Monthly Gross Income:
 ($)
Your Spouse's Years on the Job:
 Spouse's Employed Address
YourW2 2006:
 ($) Your W2 2006 ($)
Spouse's W2 2006:
 ($) Spouse's W2 2006 ($)
Your Most Current YTD Paycheck Stub:
 ($) Spouse'sMost Current YTD Paycheck Stub: ($)
Do you have 2005 and 2006 tax Returns?
Yes No
401K($):
IRA($):
Stocks($):
Bonds($):
Checking\Savings($):
Do you authorize The Binghamton Mortgage Company to review your credit history?
Yes No
How would you like us to contact you? E-mail Telephone By Mail
Binghamton Mortgage Company is a New York State Registered Mortgage Broker.
All loans are provided by third party lender.
©2005 Binghamton Mortgage Company
4747 Vestal Parkway East, Vestal, NY 13850
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