Reliable Homes Inc. - Manufactured Housing

3672 S. Pacific Hwy
Medford, OR 97501

PRE-QUALIFY FOR A NEW MANUFACTURED HOME

APPLICANT INFORMATION
First Name:
Middle Initial:
Last Name:
Street Address:
City:
State:
Zip:
How Long at Present Address:
Home Phone Number:
E-Mail Address:
Birthday (MMDDYY):
Social Security Number:
Number of Dependents:

APPLICANT EMPLOYMENT INFORMATION
Employer's Name:
City:
State:
Work Phone Number:
Position:
Monthly Income:
Hire Date:
Previous Employer:
Previous Employment Length:
Other Income:
Source:

CO-APPLICANT INFORMATION (only if both applying)
Name:
Social Security:
Date of Birth:

CO-APPLICANT EMPLOYMENT INFORMATION (only if both applying)
Employer's Name:
City:
State:
Work Phone Number:
Position:
Monthly Income:
Previous Employer:
Previous Employment Length:
Other Income:
Source:

LOAN INFORMATION
Are you Interested in a home in a Park or a Land Home?
Approx. Purchase Price:
Amount of Down Payment:
Desired Monthly Payment amount:

NEAREST RELATIVE INFORMATION
Name:
City and State:
Phone Number:
Relationship to Applicant:

BANK INFORMATION
Bank Name:
Type of Account(s):	CheckingSavings

COMMENTS

Please click on the "submit" button below if you agree to the following: I certify that the information above is true and correct. I authorize Reliable Homes, Inc. to verify any information in this application or in other documents required to obtain the loan I am requesting. I also authorize any party named in this application to provide any and all information to Reliable Homes, Inc. I am also authorizing Reliable Homes, Inc. to retrieve my credit reports along with my co-applicant (If needed). I understand that I may submit my application to Reliable Homes, Inc. electronically on this secure server. I understand that Reliable Homes, Inc. has taken every precaution necessary to secure this site. Reliable Homes, Inc. is unable to insure that the data cannot be intercepted by third parties. In the event that a third party interception should occur, Reliable Homes, Inc. will not be held liable.