Loan Request > Online Loan Request Please provide us with the information requested below. We'll contact you promptly regarding the status of your application. All information will be kept strictly confidential. Loan Qualification Is your loan over $1,000,000? Yes No Applicant Information I am a: Borrower Broker Full Name: Email: Phone Number: Mobile Number:     Property Information City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Property Type: hotels and motels industrial land long term care facilities medical facilities mixed use properties mobile home parks multi-family apartments office buildings retail buildings single tenant properties special purpose buildings assisted living facility adult care facility clinics CCRC facilities congregate care facility hospitals independent and senior housing medical office buildings nursing homes surgery centers Gross Revenue: Expenses (Excluding debt services and depreciations): Gross Profit: This property has been renovated: Yes No Property Description Please tell us the size, use, condition, and any other pertinent information about the property. Date of Purchase:   Month: -- Please Select -- January February March April May June July August September October November December Year: (yyyy) OR Purchase is Pending Purchase Price: Current Property Value: I have a written appraisal Loan Information I need a loan of: Credit Score: -- Please Select -- Less than 600 601-680 Above 680 Dominion offers hard money and flexible commercial loans Purpose of Loan (Use of Funds) Additional Notes Is there any additional information we should know about this property, borrower, or situation to provide you with a fast, reliable answer? How did you learn about Dominion?     An electronic signature is considered to be obtained when you click the “submit button” approving Dominion Mortgage and Dominion Healthcare Corporation to send you future e-mails and faxes.

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