Customer
First Name:		Email:
Last Name:		Phone:
Company:		Fax:

Property
Street Address:		County:
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:
Occupany Status:	Please select Primary Residence Seconday Residence Investment Property	Agent:
Borrower's Address:		Agent Phone:
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:
Seller's Address:
City:		Agent:
State:	ZIP:	Agent Phone:

Lender
Loan Purpose:	Please select Purchase Cash-Out Refinance No Cash-Out Refinance	Loan Amount:
Purchase Price:		Est. Closing Date:
Lender:
Loan Officer's Name:		Officer's Phone:
Closing Protection  Letter (CPL):	Not Needed Needed	CPL Lender's Name:
CPL Lender's Address:		CPL Lender's City:
CPL Lender's State:		CPL Lender's ZIP:

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