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Global Consultants Direct
350 Motor Parkway, Suite 210
Hauppauge, New York 11788

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          Applicant          Co-Applicant
          Amount Requested*
      $ 		          Purpose of Loan*
        
          First Name*
         		          First Name
        
          Last Name*
         		          Last Name
        
          Street Address*
         		          Street Address
        
          City*
         		          City
        
          State*
         		      Zip*
  
          State
         		    Zip
  
          Social Security
         - - 		          Social Security
         - -
          Home Phone*
         		          Home Phone
        
          Work Phone*
         		          Work Phone
        
          Present Market Value:
         $ 		         Original Purchase Date:
         
          1st Mortgage Balance:
        
         2nd Mortgage Balance:
         $
          1st Mortgage Holder:
         $ 		         2nd Mortgage Holder:
         $
          Interest Rate: %          Interest Rate: %
          Current Payment:
          $ 		         Current Payment:
         $
     Employment
Employer
Employer
          Name:
         		         Name:
        
         Income:
         $ 		         Income:
         $
         Position:
         		         Position:
        
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         E-Mail*:
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