I have read and agree to the Privacy Statement

Select Yes No

I understand that my details may be passed to lenders for assessment and credit checking. A note of my credit check will be made on credit reference files.

Select Yes No

Please indicate if the mortgage will be for a local or overseas property

Select Local Property Overseas Property

Name

Date of Birth

Smoker

Select Non-Smoker Smoker

Select Non-Smoker Smoker

Male / Female

Select Male Female

Select Male Female

Purchasing position

Select First time buyer Remortgage House move

Select First time buyer Remortgage House move

Occupation

Employment Status

Select Employed Director Self Employed Mixed Not Employed Retired Houseperson

Select Employed Director Self Employed Mixed Not Employed Retired Houseperson

How long in present job

years months

years months

Annual Income

Other Income

Is your income likely to change significantly in the forseeable future?

Select Yes No

Select Yes No

If your income is likely to change, give details of approximate timescale and reason:

Purchase Price / Property Value

Loan Required

Term of Loan

years

Type of Loan

Interest Only Repayment

please select Capped Cash Back Discounted Fixed Interest Flexible Standard Variable

or % split if required:

Interest Only Repayment

please select Capped Cash Back Discounted Fixed Interest Flexible Standard Variable

If "Interest Only", specify repayment method

Select Endowment ISA Pension Other

Do you require life cover to protect your mortgage in the event of death?

Select Yes No

Does this mortgage expire after retirement of either applicant?

Select Yes No

If "Yes", have the financial consequences been explained?

Select Yes No

Name of your existing lender

Does your existing loan/mortgage have a redemption penalty?

Select Yes No

Details:

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YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON A MORTGAGE OR ANY OTHER DEBT SECURED ON IT.