7447 West Talcott Avenue, Suite 300      Chicago, Illinois  60631
Phone: (773) 775-0811    Fax: (773) 775-0818

Application for Financing First Name: ___________________   Initial: _____     Last Name: ____________________________ Street Address: ___________________________________________________________________ City, State, Zip Code: _______________________________________________________________ How Long at Current Address?: ________  years, _______ months.               Own    /    Rent     /   Other Social Security No.: ________________________  E-mail: _________________________________ Housing Payment :  $_____________  per month.       Home Phone:  ___________________________ Birthdate:  (dd)_____ (mm)______ (yy) ______   Mother's Maiden Name: _____________________ Name of Employer/Business: _________________________________________________________ Employer Address: ________________________________________________________________ Employer Phone: _________________________  Your Position: _____________________________ How Long at this Company ?:  ________  years, _______ months.             Owner    /   Partner    /   Principal Salary: $_______________ per year        Household Income: $_______________ per year *Other Income: $_______________ per year       *Source: ___________________________________ *Alimony, child support or separate income need not be revealed if you do not desire such information to be considered by the bank in making a credit decision. Previous Employer (if above is less than 2 years): __________________________________________ Previous Employer's Address: _________________________________________________________ Years With Previous Employer: ___________ Retired / Unemployed / Other (describe): _________________________________________________

Kevin L. Sullivan, MD  7447 W. Talcott Ave, Suite 300  Chicago, Il  60631 Phone: (773) 775-0811                   Fax: (773) 775-0818