Loan Amount Required

Pay Loan Over

Purpose of loan

Payment Protection

I/we would like my/our loan covered by life insurance, Accident, Sickness, and Redundancy Cover.

Single Cover

No Cover

Double Cover

E-Mail

Personal Details

Home Owner

Separated

Married

Single

Divorced

Widowed

First Names

Surname

Date of Birth

Previous Names

Partners Details (Joint Application Only)

First Names

Surname

Date of Birth

Your Address

Postcode

Time at Address

Yrs.

Home Phone

Mobile Phone

No of Dependant children

Previous Address if you have lived at current address for less than three years

Time at Address

Yrs.

Your Work

Note: If you are self employed please state your occupation and how long trading

Yrs.

How long have you been employed there

Occupation

If joint application please give details of partners employment

Yrs.

How long have you been employed there

Occupation

About Your Home (Home Owners)

Approximate Mortgage Balance

Monthly Mortgage Payment

Total Arrears (if any)

Highest Arrears in last 12 Months

Original Amount Borrowed
(incl. any further advances)

Name of Mortgage Company

Address of Mortgage Company

Type of Property

House

Flat

Maisonette

Detached

Property Is

Terraced

Semi-Detached

How Many Bedrooms

How Many Reception Rooms

Year of Purchase

Current Value

What did you Pay for your Home

Is Home owned

By Yourself

By Yourself & Partner

About Your Home (Non-Home Owners)

Monthly Rental Payment

Your Bank Details

Time Account open

Your Income

Your Gross (before stoppages) Income with any overtime or bonuses. if self employed your Net Income.

Your Income

If joint application please give details of partners income

Partner's Income

Declaration: I/We hereby declare the above details are correct. By signing this declaration you agree that you have received permission from the client to allow us and any lender(s) to whom we submit their application for a loan may make or obtain enquiries, searches and references about the client from any person, including any credit reference agency (which will keep a copy of any searches made) at any time prior to the making of the loan or whilst monies are owing under it.

I agree to above declaration