Welcome to Fidelity National Title

REFI TITLE AND ESCROW SERVICES

* Required Fields

YOUR INFORMATION

*Your Name:
*Email Address:
*Service Requested:
*Policy Type Requested:
Your Title Officer:
Your Escrow Officer:
*Ordering Party Is:	Other: (Required if Other is selected)
Reference #:
BORROWER INFORMATION

Borrower Name:
Borrower SSN : *
Co-Borrower Name:
Co-Borrower SSN: *
Address:
City:
State:
Zip:

Phone:	( ) - ext
Fax:	( ) - ext
Cell Phone:	( ) -
Pager:	( ) -

LENDER INFORMATION

Company:
Loan Officer:
Email Address:
Address:
City:
State:
Zip:

Phone:	( ) - ext
Fax:	( ) - ext
Cell Phone:	( ) -
Pager:	( ) -
Mortgage Broker:

TRANSACTION INFORMATION
Refinanced Loan Amount:
Loan Type:	Other: (Required if Other is selected)
Loan Position:	Other: (Required if Other is selected)
PAYOFF INFORMATION

Payoff Loan #:
Payoff Amount:
Payoff Lender's Name:
Payoff Lender's Address:
Payoff Lender's City:
Payoff Lender's State:
Payoff Lender's Zip:

Payoff Lender's Phone:	( ) - ext
Payoff Lender's Fax:	( ) - ext
Cell Phone:	( ) -
Pager:	( ) -

SECOND PAYOFF INFORMATION

Payoff Loan #:
Payoff Amount:
Payoff Lender's Name:
Payoff Lender's Address:
Payoff Lender's City:
Payoff Lender's State:
Payoff Lender's Zip:

Payoff Lender's Phone:	( ) - ext
Payoff Lender's Fax:	( ) - ext
Cell Phone:	( ) -
Pager:	( ) -

SUBJECT PROPERTY INFORMATION
Property Type:	Other: (Required if Other is selected)
Address:
City:
State:
Zip:
County:
MAILING ADDRESS(Complete only if different from subject Property Address)
Address:
City:
State:
Zip:

SPECIAL INSTRUCTIONS
Special Instructions:
*Your Sales Representative:

Disclaimer: This site is not designed for the transmission of highly confidential customer, non-public personal information, and should therefore not be used to enter or transmit data such as customer Social Security Numbers or Driver's License Numbers.

*Your FNTIC representative will contact you directly for this information.