Primary Applicant Name: Co-Applicant Name: Street Address: City: State: Zip Code: Home Phone: Example: (808) 123-4567 Work Phone: Example: (808) 567-8901 Type of Property: Single Family Multi Family Investment Property Location of property: Street, City State Zip Estimated Value: Gross Yearly Income: Example: 60,000 Percent Down Payment: Time to close: How is your credit? Make your best guess... Excellent Good Fair Poor Best Time To Contact You: Choose one... Morning at Work Afternoon at Work Evening at Work Morning at Home Afternoon at Home Evening at Home Loan Amount Desired: (Must be at least $20,000) Example: 80,000 Your E-Mail Address: Must be in form: name@domain.com. Please verify. Thanks! Please verify your information - especially your telephone numbers and e-mail address - before pressing the button.

Have questions? Contact us first! Toll Free 1-866-811-9900 for a free pre-approval Licenced by the Pennsylvania Department of Banking. This page is not secure. While highly unlikely, this form can be intercepted in transit. Fill out only the parts you are comfortable with and be sure to include a phone number so we can contact you to get additional information. We will be happy to finish your application over the phone.

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Phone: 570-421-7404
Fax: 570-421-7414

Email: info@lewismortgage.com