• Company Name:
• Company Address:
• Company Address:
• City:
• State:
• Zip:

• Your First Name:*
• Your Last Name:*
• Phone:
• Alternate Phone:
• Fax:
• E-mail:*

• Loan Officer:
• File Number:

• FHA?:
• If Yes: FHA Case Number:

• Owner Name:*
• Address:
• City:
• State:
• Zip:
• County:

Appraisal Purpose:

• Purchase:
• Refinance:
• Non-Loan Market Value:
• Other:

• Estimated Value:
• Sale Price (if applicable):

• Loan Amount:
• Property Type:

• Contact for Entry:*
• Contact Phone:*
• Contact Alternate Phone:

• Report Type (i.e., 1004, 1025, 1055, etc):

Payment Type:

• Borrower COD:
• Lender COD:
• Bill Lender:

• Comments:
• Security Code:*
•