Call in form Use this form to qualify mortgage callers for credit repair. The form results will be emailed to you. Incoming Call Script First Name * Last Name Thank you for calling, (name). How are you today? ____Are you calling to purchase or refinance a home? Loan Purpose * Purchase Refinance Home Equity Loan Construction Stop Foreclosure Is this the best number to reach you on? Home Phone Number Is that a mobile phone? Cell Phone Number (10 digits) State where the property is located State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Current Zip Code * May I have your Email Address Email Property Type * Single Family and up to 4 units Multi-Family Commercial Mobile Home Condominium Have you already found a house? Yes No If you have found a house, provide the address. Do you want to get help to find a house? Yes No Combined Annual Income What is the property value or price range? How much do you want to borrow? Do you know your credit score? * Poor 619 or below Fair 620 - 669 Good 670 - 739 Excellent 740 + What negative items do you have on your credit report? Collections Late Payments Repossession Foreclosure Bankruptcy Identity Theft Judgements Liens Do you want to get help to improve your credit score? * Yes No What should we do with this lead? * Submit it to leads.mortgageleads.net database Email me this lead and post it to leads.mortgageleads.net Email me this info and keep it private comments Your Email Address (Where to send this info) Put your email address here if you want a copy of this lead.