Introducer Details

Company Name:*
Contact Name:*
Main Phone No:*
E-mail Address:*
CCL No:*

Loan Details

Loan Type:*		Secured Personal
Amount of Loan:*		£
Term:*		years
Purpose of Loan:*

Applicant Details

		Applicant One		Applicant Two
Title*		Mr Mrs Miss Ms Dr Sir		Mr Mrs Miss Ms Dr Sir
Forename*
Middle Name*
Surname*
Previous Name
Date of Birth*		/ / (DD/MM/YYYY)		/ / (DD/MM/YYYY)
Marital Status*		Single Married Cohabiting Divorced Separated Widow Widower		Single Married Cohabiting Divorced Separated Widow Widower
Nationality
Current Address*
Postcode*
Time at Address*		years months		years months
Previous Address* if Less than 3 years at current
Postcode*
Home Telephone No*
Mobile Telephone No*

Property Details

Residential Status:*		Owner Tenant
Property Type:*		Terraced Semi-Detached Detached Bungalow Mainsonette Flat Ex-Council
If Ex-Council did you receive a discount:		£
If Flat how many floors:*
Number of bedrooms:*
Property Construction:*		Standard Non-Standard
Date of Purchase
Purchase Price:		£
Current Value:*		£

Mortgage Details

		Current Mortgage		Any Other Secured Loans
Name of Lender*
Account Number
Balance Outstanding*		£		£
Monthly Repayment*		£		£
Any missed payments in last 12 months*		Yes No		Yes No
Current Arrears*		£		£
Highest Arrears in Last 12 Months*		£		£
Last three payments made*		Yes No		Yes No

Income

		Applicant One		Applicant Two
Gross Annual Income*		£		£
Other Income		£		£
Source of other income
Time in Job*		years months		years months
Occupation*
		Employed Self-Employed Houseperson Unemployed		Employed Self-Employed House-person Unemployed
Personal loan customers must complete this section.
Employers Name
Employers Address		Postcode:		Postcode:
Telephone Number
If Self-Employed can you supply 2 years of audited accounts?		Yes No		Yes No

Bank Details

Personal loan customers must complete this section.

		Applicant One		Applicant Two
Bank
Time at Bank		years months		years months
Sort Code		- -		- -
Bank Account Number
Name(s) of Account Holder

Additional Information:

Declaration: I am authorised to act as agent for and on behalf of ALL applicants in connection with this loan application. I confirm that I am acting within my authority and that I have obtained the verbal consent of each and every applicant that, in relation to the applicants personal information you may:

1.Process it (automatically or otherwise)for the purposes of this application;
2.Search and/or disclose it to credit reference agencies, lenders and/or third parties provided they use it for the purposes for which you may use it for fraud prevention;
3.Where a search and /or disclosure is to a credit reference agency, the applicants understand that records may be kept;
4.Check it with a fraud prevention agency and if false or inaccurate information is provided or you suspect fraud,this will be recorded.

I confirm that I have explained to the applicants that you and other organisations may use and search the records of fraud prevention agencies to help make decisions about credit related services, and /or on motor, household,credit,life and other insurance proposals and claims for the applicants or members of their household; to trace debtors,recover debt,prevent fraud and to manage the applicants accounts or insurance policies and to check the applicants identity to prevent money laundering,except where satisfactory proof of identity has been provided.

The applicants understand that you may wish to obtain personal information(the accuracy of which is their responsibility)in writing,by telephone or in electronic form and agree that you may also obtain information about them from brokers or other third parties together with credit reference agencies,in particular,but not limited to,Experian,CAIS,Cifas,Equifax Europe,Insight and other associated companies.The applicant has been advised of their rights under the Data Protection Act 1998;that you will hold the personal information in your records and the applicants have the right to obtain a copy on payment of a fee.The applicants understand that any telephone calls made may be recorded and monitored for security,quality and /or training purposes.