Applicant Information

Full Name *

Date of birth *

Phone *

Email *

Driver's License Number *

State Issued *

Property Information

Address

Street Address *

City *

State *

Country

Postal Code *

Is this your primary residence? *

Yes

Do you own the property? *

Yes

Type of home: *

Single-Family

Townhome

Duplex

Other

Employment & Income

Employment Status: *

Employed

Self-Employed

Retired

Other

Employer Name (or Business Name if self-employed) *

Job Title *

Time with Employer (years/months) *

Monthly Gross Income (before taxes) *

Housing & Financial

Do you currently have a mortgage on this property? *

Yes

Monthly mortgage payment (if applicable) *

Do you have any open bankruptcies or foreclosures? *

Yes

If yes, please explain (short answer): *

Payment Preference

Preferred financing term: *

Short-term (3–6 months)

Mid-term (6–12 months)

Long-term (12+ months)

Expected source of repayment (check all that apply): *

Insurance recoverable depreciation

Insurance supplement

Personal funds

Other

Authorization & Acknowledgements

I certify that the information provided is true and accurate.

I understand that approval is not guaranteed and is subject to internal review.

I authorize RCUSA – Roofing & Construction to verify the information provided.

I agree that failure to repay may result in collection efforts and/or legal action per agreement terms.

Electronic Signature *

Clear

Date *

Flexible In-House Financing for Homeowners

Get the work you need now — pay over time.

Applicant Information

Property Information

Project Information

Employment & Income

Housing & Financial

Payment Preference

Authorization & Acknowledgements