P.O.M. PLANNING SERVICES, INC

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Homeowners

Please type a question mark(?) if you don't know the answer, and we will explain to you when we contact you.


Applicant's Name * :

Telephone Number * :

Email * :

Address * :

Applicant #1 Name/DOB/SSN * :	/ /

Applicant #2 Name/DOB/SSN * :	/ /

Occupation :

Purchase Price :

Amount Mortgaged :

Name of the Mortgagee :

Type of Construction :	Brick Frame Other

Size in Square Foot :

Number of Families :

Number of Stories :

Number of Garages :

Swimming Pool? :

Burglar Alarm Installed? :	Yes No

Heat Type :	Gas Electrical Oil Other

Location of Oil Tank (If oil is selected) :	Underground Above ground

Occupancy :	Owner Occupied Tenant Occupied Both

Loss/Claim in the last 3 years :	Yes No

Additional Information :