Secured Loan Form

* Indicates required fields

Introducer Details

Title: * Please select Miss Mr Mrs Ms Dr

First Name: *

Last Name: *

Company:

Email: *

Phone: *

Address Line 1: *

Address Line 2:

Address Line 3:

Address Line 4:

Town: *

County:

Postcode: *

Details for Client 1 (Principle Contact)

Please enter here the client's residential address.

House Number:

Address Line 1: *

Address Line 2:

Address Line 3:

Address Line 4:

Town: *

County:

Postcode: *

Is this the client's main address?: Yes No Unknown

Previous Addresses: Please enter all the addresses in which you have lived for the past three years, if the address above is not the only one.

Title: * Please select Miss Mr Mrs Ms Dr

First Name: *

Surname: *

Date of Birth: * day month year

Phone (work):

Phone (home):

Mobile:

Email (work):

Email (home):

Income Details

Total Gross Income / Annum: *

Applicant's Employment Type: * Please select Employed Self-Employed

Income Verification: * Please select Status Self-Cert

Is there income evidence available?: * Please select Yes No

Income evidence type: * Please select Payslips P60's Tax Return Accounts (1 year) Accounts (2 years) Accounts (3 years)

Time Employed/ Self-Employed: * (In years and months)

Requirement

Amount Required (£): *

Broker Fee Required (£): * (If not required, please enter 0)

Term of Loan (years): * Please select 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Insurance Regulation Notice: *

Do your customer(s) require information regarding the lenders payment protection? Please select Yes No

Purpose of Loan: *

Repayment Method: * Please select Capital and Interest Repayment Interest Only

Mortgage Details

Present Mortgage Balance (£): *

Current Lender: *

How long with current lender: * Years Months If an exact number of years, enter 0 in months

How long with previous lender: Years Months If an exact number of years, enter 0 in months

Monthly Payment (£): *

Account Number:

Repayments missed (last 12 months): * (Please enter a whole number)

bankruptcy: * Have you ever been bankrupt? Please select Yes No

Details of Property against which the Loan is to be Secured

Purchase Price (£): *

Current Valuation (£): *

Property Location: * Where is the property? Please select England Wales Scotland Northern Ireland

Property Use: * What is the property use? Please select Residential Buy to Let

Property Type: * Please select House Flat Maisonette Other

If Other, what type? *

Property Construction: * Is the property of normal construction? Please select Yes No

If No, what type of construction is it? *

Property Ex-council: *

Flats:

Above Shops: Please select Yes No

Semi-Commercial: Please select Yes No

Details of Security Property

House Number:

Address Line 1: *

Address Line 2:

Address Line 3:

Address Line 4:

Town: *

County:

Postcode: *