MORTGAGE BENEFIT ENROLLMENT FORM

Personal Information

Please complete each field and check each box prior to enrollment form submission.

First Name

Last Name

Email address

Job Title

Company Information

Company Name

Address 1

Address 2

City

State

Zip Code (e.g. 12345)

Work Phone

Website URL

Total Number of Employees

I, the applicant, possess authority to render executive decisions on behalf of the above stated company in terms of enrollment in employee benefit programs.

Terms and Conditions

The following terms and conditions are presented by Provident Funding Associates ("Provident Funding", the "Lender") to govern participation in the Provident Funding Mortgage Benefit Program® (the "Program"). To participate in the Program, the applying company (the "Company") agrees to the following:

Company shall from time to time in its discretion inform its employees or members of the Program.
Employees and members shall apply for a mortgage loan by submitting an application to Lender via its website www.provident.com, including with each application a coupon code supplied by Lender to Company.
For each loan application that is approved, Provident Funding shall provide a discount on the loan origination fee that it would ordinarily charge a borrower. Provident Funding may change the amount of such discount or discontinue the Program in its sole discretion, following notice to Company.
Company is not obligated to cause any of its employees or members to apply for a mortgage loan from Provident Funding, and Provident Funding is not obligated to make a mortgage loan to an employee or member of Company.
Company will inform Provident Funding in writing if its number of employees declines to less than 25, in which case Provident Funding reserves the right in its sole discretion to discontinue Company's participation in the Program.

By checking this box, I acknowledge on behalf of the Company its agreement to these terms and conditions and that I am authorized to do so as a representative of the Company.