Title:

First Name:

Last Name:

Address:

Postcode:

Home phone:

Work phone:

Mobile:

When can you be contacted?

 Daytime  Evening  Weekend

Email address:

Are you or your partner a homeowner/mortgage payer?

Yes No

Current mortgage lender?

Other lender, if not listed above

Any redemption penalties?

No Yes Not sure

Joint or Single Enquiry

Joint Single

1st enquirer date of birth

Employment

Your income

2nd enquirer's date of birth

2nd enquirer's employment

2nd enquirer's income

Do you need self-certification of income?

No Yes

Could you/ joint enquirer have a problem proving your income?

No Yes

Minimum remortgage amount required

Maximum mortgage amount required

Approx. value of your property

Original cost of property

Date property purchased

Approximate mortgage outstanding (if applicable)

Approx. value of secured loan(s)

Who is your secured loan lender

Other lender, if not listed above

Approx total other loans

Reason for remortgaging

Other reason for remortgaging (if applicable)

Please list any other reasons for remortgage

What problems are you having finding a remortgage?

Have you had a mortgage refused elsewhere?:

No Yes

Please read carefully: If you suspect that you currently have a less than perfect credit history or suspect you have EVER had any credit problems whatsoever, please tick. Before a lender provides you with a mortgage they will ALWAYS perform a credit check and will discover your actual credit history. Not declaring it at this stage may count against you.

None
Defaults
Arrears
CCJs
IVA
Bankruptcy
Late/missed loan payments
More than 1 or other‚ please record below

Any questions, comments or brief details of any credit issues (eg arrears, IVAs, defaults,CCJs)

Would you like an assessment of your life insurance payments? (you are probably paying too much):

Yes No

May a credit check be performed?

Yes No

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