DATE:____________                  PURCHASE:________________OR RE-FINANCE:____________

BORROWER NAME:_____________________________CO-BORROWER:______________________________

REALTOR________________________________________CONTACT_______________________________

PHONE______________________________________FAX____________________________________________

TITLE COMPANY_______________________________________CONTACT_______________________________

PHONE______________________________________FAX____________________________________________

APPRAISER_______________________________________CONTACT_______________________________

PHONE______________________________________FAX___________________________________________COLLECT FEE AT DOOR: YES_____NO_____PAID AT CLOSING: YES____NO____

HOME OWNERS INSURANCE______________________________________CONTACT_________________________________

PHONE_____________________________________FAX____________________________________________

CHOICE OF LENDER____________________________________CONTACT_______________________________
(PLEASE ATTATCH ANY PRE-QUALIFICATION RECEIVED FROM LENDER)

CAN WE CONTACT YOUR BORROWER IN REFFERENCE TO THIS LOAN? YES_______NO_______

CONTACT OTHER THAN BORROWER FOR INFORMATION ON THIS LOAN _________________________________________PHONE____________________________________________

YOUR INFORMATION: BROKER CONTACT________________________________________________________

PHONE_______________________FAX_______________________E-MAIL_____________________________

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