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Introducer details:
Firm Name:
Contact Name:*
Contact Number:*
Email Address:*
Fax Number:
Business Address:
Network/Packager:
BDM Contact Name:
FCA Number:
CCL Number:

Next

Is the application from a Limited Company/Limited Liability Partnership?
Yes No

Company/LLP Name:
Registration Number:

How many applicants are there (individuals, shareholders or partners)?

1 2 3 4 5 6

Customer details:
Name:
Residential Address:
Email Address:
Contact Telephone Number:
Date of Birth:
Occupation:
Net Income (After Tax):
Net Asset Value (of customer):

Customer details:
Name:
Residential Address:
Email Address:
Contact Telephone Number:
Date of Birth:
Occupation:
Net Income (After Tax):
Net Asset Value (of customer):

Customer details:
Name:
Residential Address:
Email Address:
Contact Telephone Number:
Date of Birth:
Occupation:
Net Income (After Tax):
Net Asset Value (of customer):

Customer details:
Name:
Residential Address:
Email Address:
Contact Telephone Number:
Date of Birth:
Occupation:
Net Income (After Tax):
Net Asset Value (of customer):

Customer details:
Name:
Residential Address:
Email Address:
Contact Telephone Number:
Date of Birth:
Occupation:
Net Income (After Tax):
Net Asset Value (of customer):

Customer details:
Name:
Residential Address:
Email Address:
Contact Telephone Number:
Date of Birth:
Occupation:
Net Income (After Tax):
Net Asset Value (of customer):

Is the application for a Regulated Mortgage Contract?
Yes No
Net amount required by the applicants?
Do you require fees to be added to the loan?
Yes No
Length of time required by the applicants
Is the loan to fund a purchase?
Yes No

Next

Primary Security details: Property being purchased, developed or other main security
Property Type:	Residential Commercial Mixed Use Land
Property Address:
Property Postcode:

Are the applicants intending to develop the property?
Yes No

Next

Is there any outstanding mortgage on the property?
Yes No

Is there any additional security available?
Yes No

Next

Do the applicants require retained interest?
Yes No

How do the applicants intend to repay the loan?

Next

Do you have details of the applicant's solicitors?
Yes No

Solicitors details:
Firm name:
Solicitors name:
Address:
Email address:
Contact telephone number:

Have you instructed a valuation?
Yes No

Please provide any addtional information which is relevant to the application: