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SECTION ONE:

The letter accompanying the consumer's video will contain your company's contact information. Please complete the following information as you would like it to appear in the letter.
 
Company Name:*
Contact First Name:*
Contact Last Name:*
Security Question: What is your mother's maiden name?*
Company Designation:* Banker Broker
Address:*
Address (Line Two):
City:*
State:*
Zip Code:*
Phone Number / Ext:*
Cell Phone:*
Fax Number:*
Email Address:*
Web Address:
Is the billing info different from the contact info?* Yes No
Billing First Name:
Billing Last Name:
Billing Address:
Billing Address (Line Two):
Billing City:
Billing State:
Billing Zip Code:
Billing Phone Number / Ext:
Billing Fax Number:
Billing Email Address:
 
General Information
 
Name of Your LLS Account Manager (if applicable):
Are you a HUD approved originator?:* Yes No
Year Founded:*
Total number of loan originators in your office:*
States approved to offer reverse mortgages in:*
Available States
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Your Selected States
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