Last Name
First Name
Middle Name
Jr. or Sr.
Date of Birth
Social Security #
Street Address
City
State
Zip Code
Years at this Address
Contact Phone
Your E-Mail Address
Current Employer
# of Years with Employer
Monthly Gross Income
# of avg hours per week
Other Income
Have you ever filed bankruptcy
If yes, give discharge date
Are you self Employed
Have all tax returns been filed
that are currently DUE
Has any agent or Lender
ran your credit report in
the last 30 days
If yes, whom
Have you ever defaulted on
a student loan
Have you ever had a home
go into foreclosure
Current Rental Amount
Desired Monthly House
Payment, (Payments start $775)
Are you currently working
with or being represented
by a real estate agent
If yes, Name and Number
How soon are you wanting
to move

How did you hear about us
Additional Comments
By hitting the submit
button you are authorizing
us to run your credit report
for pre-qualification
purposes.
Hit the submit button
ONE time.
To fill out on line, just fill in the blanks and hit the submit button.  Your information is not shared
with ANYONE other than a Mortgage Lender for the purpose of qualifying for a home.  During
regular business hours we will contact you almost immediately and tell you how we can help.  
During weekends and nights, we will call you within 24 hours.
Jerry Butler Homes, 5068 Murfreesboro Rd., La Vergne, TN 37086