| First Name: | |
| Last Name: | |
| Address Street 1: | |
| Address Street 2: | |
| City: | |
| Zip Code: | (5 digits) |
| State: | |
| Email: | |
| Daytime Phone: | |
| Evening Phone: | |
| Whats is the best time to call you?: | |
| Would prefer to speak with someone in Spanish?: | |
| I am interested in the following program:: | |
| Where did you hear about us?: | |
| State Licensed: | |
| Tell us about your credit ?: | |
| How long have you been in the mortgage business?: | |
| How many loans have you actually written start to finish?: | |
| Average of closed loans per month: | |
| How are you currently generating your business?: | |
| List 4 positive attributes about yourself: | |
| Have you ever given a presentation to a group of people? | |
| How would you market the RemoveMYbills name to gain exposure in your area?: | |
| What is your monthly marketing budget?: | |
| Describe your business goals?: | |
| Personal skills, strengths and experience that you have that will make you an asset to our company: | |
| Do you feel comfortable leading a team of professionals?: | |
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