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Bold = required information    
Customer    
First Name: Email:
Last Name: Phone Number:
Company Name: Fax Number:

Property
Street Address: Country:
City: Parcel ID:
State:
ZIP:
Legal Description:

Buyer/Borrower
Borrower's Name: Borrower's SSN:
Co-Borrower's Name: Co-Borrower's SSN:
Marital Status: Borrower's Phone No:
Occupancy Status: Agent:
Borrower's Address: Agent Phone No:
City: Deposit Held By:
State:
ZIP:
Deposit Amount:

Seller (leave blank if refinancing)
Seller's Name: Seller's SSN:
Co-Seller's Name: Co-Seller's SSN:
Marital Status: Seller's Phone No:
Seller's Address:  
City: Agent:
State:
ZIP:
Agent Phone No:

Lender
Loan Purpose: Loan Amount:
Purchase Price: Est. Closing Date:
Lender:  
Loan Officer's Name: Officer's Phone No:

Additional Information
First Mortgage Co: Second Mortgage Co:
Loan #: Loan #:
Phone Number: Phone Number:
Survey:
Needed Not Needed
Hazard Insurance:
Termite Inspection:
Needed Not Needed
Hazard Ins. Phone No:
Association:
Yes No
Association Phone No:
Comments:

 

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