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Introducers Form

Broker Details

Name (*)	Company Name (*)
Contact Number (*)	Email Address (*)

Client Loan Requirements

Loan Amount Required? (*)	Loan Repayment Term
(£)	Enter 3 – 25 yrs
Purpose of Loan

Client(s) Details

Number of Applicants (*)
One Two
Applicant 1	Applicant 2
Title (*) Applicant 1	Title Applicant 2
Please select Mr Mrs Miss Ms Dr	Please select Mr Mrs Miss Ms Dr
Name (*) Applicant 1	Name (*) Applicant 2
Date of Birth (*) Applicant 1	Date of Birth Applicant 2
Day 1 2 3 4 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 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920	Day 1 2 3 4 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 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Status	Status Applicant 2
Married   Single Living Together Divorced Widowed / Separated	Married   Single Living Together Divorced Widowed / Separated
Telephone Number (*) Applicant 1	Telephone Number Applicant 2
Mobile Number (*) Applicant 1	Mobile Number Applicant 2
Current Address (*)
Post Code (*)
How long have they lived there? (*)
Years Months (if less than 3 years add your previous address in the box below)
Name of Bank / Years with Bank (*) Applicant 1	Name of Bank / Years with Bank Applicant 2
years	years
Bank Account Number (*) Applicant 1	Bank Account Number Applicant 2
Sort Code (*) Applicant 1	Sort Code Applicant 2
e.g. 40-26-56 reads 402656	e.g. 40-26-56 = 402656
Number of Dependents (below 18 years of age) (*)

Client(s) Employment Details

Applicant 1	Applicant 2
Occupation (*)	Occupation
Employment Status (*)	Employment Status
Please select Employed Self Employed Unemployed	Please select Employed Self Employed Unemployed
Time in Job? (*)	Time in Job?
Years  Months	Years  Months
Monthly Gross Income (Including Overtime & Bonus) ? (*)	Monthly Gross Income (Including Overtime & Bonus) ?
(£)	(£)
Details Of Other Income	Details Of Other Income

Property Details

Type of Property(*)	Construction Type (*)
Detached    Semi-Detached   Terraced  Bungalow  Flat / Maisonette	Standard Non-Standard
Accomodation - number of : (*)	Is Property Ex-Council? (*)
Bedrooms Living Rooms Kitchens	Yes No £'s Discount Given
Bathrooms WC's Garages
Shared Ownership (*)	Purchase Price? (*)
Yes No	(£)
Date Purchased (*)	Estimated Value ? (*)
Day 1 2 3 4 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 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920	approx (£)

Clients Mortgage Details

Name Of Mortgage Lender (*)	Monthly Payment (*)
How much is outstanding (*)?	Name Of Previous Mortgage Lender (If changed within last 12 months)
(£)

Additional Details

Does the Client Have Any Existing Secured Loans? (*)	Yes No
Name Of Lender?
Amount Owing?
Do They Have Any Adverse Credit History? (*)	Yes No
Other Information?
Declaration (*)
I confirm that I have read and understood the declaration statement above (*)	Yes
	Read our privacy statement here

 

Think carefully before securing other debts against your home. Your home may be repossessed if you do not keep up repayments on a mortgage or any debt secured on it. The actual rate will depend on your circumstances. Loans subject to status and secured on property. There may be a fee for arranging loans, typically between 0%-10% of the amount borrowed. Consumer credit licence no: 575401 Data protection number: z9430172
* Subject to lenders conditions

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