PERSONAL DETAILS

Title: Mr Mrs Miss Other    First Name:   Surname: Date of Birth: 

Home Telephone:    Moblie / Work Telephone:

Married:         Single:          Other: 

Full Address:

Post code:   Time at Address: years months

Previous Address: (if less than 3 years)

Post code:   Time at Address: years months

PARTNERS DETAILS

Title: Mr Mrs Miss Other    First Name:   Surname: Date of Birth: 

LOAN DETAILS

Amount Required: £     Term:  1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Please give a brief description as to the purpose of this loan:

 Do you have any CCJ's: Yes No      If yes How Many:

PROPERTY DETAILS

Homeowner:          Other:          Council Purchase: Yes No

PROPERTY DETAILS

Purchase Price: £  Date of Purchase:  

Mortgage Outstanding: £  Mortgage Payment (Monthly)  £

Estimated Value: £   Any Current Mortgage Arrears: Yes No

Highest arrears in last 12 months: £

EMPLOYMENT DETAILS

Occupation:

Self Employed: Yes No      Number of years self employed:     Take Home Pay: £     Weekly Monthly

PARTNERS EMPLOYMENT DETAILS

Occupation:

Self Employed: Yes No      Number of years self employed:      Take Home Pay: £    Weekly Monthly

DECLARATION

The information you provide will be used by us for the purposes of a assessing your application and retained on our system and may be submitted to Lenders and Master Brokers who will use it for the same purpose. Both the Lenders and Master Brokers will search your credit record at one or more licensed credit reference agencies. They will ad details of the searches to your credit record, and these May be seen by other organizations which make searches in the future. Both we and the lenders and Master Brokers may contact third parties, for example your employer or bank etc…(to be finalized)