Complete the information below. If you are interested in potentially applying for a
mortgage loan and would like to have a representative from Morrill & Janes Bank contact you by
telephone or e-mail, please submit the following information via our secure internet
website. If you have questions, feel free to contact one of our loan representatives.
If you do not wish to submit the information online, please print the completed form
and mail or deliver the form to the banking office nearest you. We have offices
in the following Kansas cities: Merriam, Hiawatha, Sabetha, Onaga and Troy, and an office in Lee's Summit, Missouri.
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By submitting this Mortgage Loan Inquiry Form, you give Morrill & Janes Bank permission for a
Loan Representative to contact you by telephone or e-mail. You also give us permission to fax any
document to the fax number disclosed on this Form when you request this method for delivering documents