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| Primary Applicant |
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| First Name: |
Middle Initial: |
Last Name: |
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| Where I/We Live Now |
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| Address: |
Apt. or Lot No: |
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| City: |
State: |
Zip: |
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| Length of Time at Current Address: |
Rent or Own: |
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| Contact Information |
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| Day Phone: |
Night Phone: |
Mobile/Cell Phone: |
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| Best time to call: |
Email: |
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| Employment & Income |
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| Time at Current Job: |
Yearly Income: |
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| Yearly Child Support Income: |
Other Yearly Income: |
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| Co-Applicant (if applicable) |
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| First Name: |
Middle Initial: |
Last Name: |
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| Co-Applicant Employment & Income |
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| Time at Current Job: |
Yearly Income: |
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| Yearly Child Support Income: |
Other Yearly Income: |
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| Describe Your Dream Home |
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| # Bedrooms & Baths: |
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Ex: 3/2 (3 bedrooms, 2 baths) |
| Type: |
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Ex: Singlewide, Doublewide or "Stick Built" Modular |
| I'd like to move when: |
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Ex: ASAP, 3 months, 6 months, etc. |
| You'll be residing in what state? |
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Ex: WV, OH |
| Desired monthly payment: |
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Total with home, land and improvements. |
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| If you already have land |
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| Owned or purchasing? |
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Choose one |
| Balance Owing: |
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Approximate amount owed. |
| Need improvements? |
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(well, septic, foundation, etc.) Yes or No |
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| Need Land? |
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| Which area? |
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Ex: Morgantown, Fairmont, Weston area. |
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| Down Payment Information |
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| Cash Down Payment |
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Maximum I/We have available to put down. |
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| Items Available for Trade-In |
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| Trade available? |
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Choose one |
| Describe in detail: |
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Ex: Mobile home, automobile, truck, boat, motorcycle, travel trailer or other. |
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Have you previously had contact with Middletown Home Sales? If so, choose your most recent method... |
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| Previous contact? |
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| Choose one |
Please keep me informed about future specials and homes that may become available. |
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By clicking the submit button below, I/We warrant the information I/We are furnishing is truthful, accurate and supplied voluntarily and therefore authorize at your option to check my credit, employment history, and bank references, to answer questions about me/us and to keep this application whether or not it is accepted.
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