*Bold Fields are Required

Transaction Type: Residential Commerical
		Refinance
		Sale Please forward a copy of the Purchase Agreement to FAX 225.769.2300 or send an email with attachments to: info@grandtitle.com
		New Construction
CUSTOMER
*First Name:
*Last Name:
*Email:
Company:
*Phone:
Fax:
PROPERTY
*Street Address:
*City:
*State:		-- Select a state -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip Code Or Postal Code:
County:
Parcel ID:
Legal Description :
BUYER/BORROWER
*Borrower's Name:			*Borrower's SSN:
*Co-Borrower's Name:			*Co-Borrower's SSN:
*Marital Status:			*Borrower's Phone:
*Occupancy Status:		--Please Select-- Primary Residence Secondary Residence Investment Property	Agent:
*Borrower's Address:			Agent Phone:
*City:			Deposit Held By:
*State:		-- Select a state -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Deposit Amount:
SELER (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: