To:

the packaging Team

From Broker Ref: Name: Tel No: Fax No:

Fax to: 01392 678 679 Tel: FAO: 0845 466 8999

1. Personal Details
Applicant 1
Applicants Name(s) Maiden Name Current Address

Applicant 2

Previous Address (If less than 3 years at current address) Date of Birth

2. Details of the Mortgage Required

Estimated Market Value Purchase Price Loan Type: Re-mortgagae Purchase FTB Proper ty Details: Is the proposed Security an Apt/Flat? Yes / No Storeys Above Commercial? Yes / No Amount of Loan Required Repayment Term Required

3. Employment Details
Applicant 1 PAYE Applicant 2 PAYE Permanent: Yes / No Self Employed Permanent: Yes / No Self Employed Self Certification Self Certification Contract Contract Period of Employment Period of Employment years years months months

Applicant 1 Gross Annual Income

Applicant 2 Gross Annual Income

4. Existing Credit
Type of Loan
Mortgage Personal Loan 1 Personal Loan 2 Personal Loan 3 Personal Loan 4 Credit Card 1 Credit Card 2 Judgements Written Off Accounts Other TOTAL
PTO

Outstanding Balance

Monthly Repayment

5. Reason for Arrears (Please provide details of circumstances, dates and amounts together with any other relevant details)

6. Other Information/Comments

7. Declaration
DECLARATION I/We understand, declare and acknowledge that: the information given on this form is true and complete to the best of my/our knowledge; you will use this information given on this form to decide, in principle, whether you would be willing to accept my/our formal application for a mort gage (if I/we make one); you may reject our formal application (if I/we make one), even if you have given your agreement in principle, especially if the information given on this form has changed by the time I/we make our formal application I/We consent to: you disclosing any of the information given on this form to the operators of the National Hunter System, the Credit Industry Fraud Avoidance System and other collective mortgage data checking systems, who may make the information available to other lenders or subscribers to their system where this is done in the interest of fraud prevention; you requesting a credit reference (which will include information that you may use for an automated credit assessment) from one or more credit reference agencies and to you disclosing any of the information given on this form to any such agencies. I/we understand that this information will then be made available to others requesting credit references against me/us and may be used, for example, in relation to future lending decisions, fraud prevention, debtor tracing, etc. I/We further understand that any credit reference agencies who you contact will keep a record of the references you request about me/us; you making any other enquiries that you consider necessary in connection with this application and to you disclosing any of the information given on this form in order to make those enquires; you disclosing the results of any (or all) of the enquires you make about me/us to the introducer of my/our application to the Society who is named on the front of this form. All applicants must sign, having first read the above acknowledgements, declarations and consents which are given by signing this form. Full Name Full Name Signature Signature Date Date

In the absence of the client(s) signature(s) above I/we confirm that the client(s) is/are aware of the terms of the above declaration Full Name Signature Date