Broker/Client Name

Broker/Client Contact

Type	Refinance Purchase

File #

Customer Name

Customer Phones: Home & Work

Closing Location

Home Work Other

If Other: Describe

Lender

Lender Contact

Lender Contact Phone

Loan Amount

Lien Position

1st 2nd Other

If Other: Describe

If Purchase:

Buyer's Attorney

Buyer's Attorney Phone

Seller's Attorney

Seller's Attorney Phone

REQUIREMENTS: PAYOFFS COPIES OF ID’S (LEGIBLE***) HAZARD BINDER W/ RECEIPT OR INVOICE OTHER PAYOFFS

Comments or Instructions