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Title:
Mr Mrs Ms Miss

Email Address:

Home Phone:
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Firstname:


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Work Phone:
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Surname:


Date of Birth:
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Mobile:
This is used to confirm your loan

House Number/Name:


Town/City:

Home Type:
Homeowner Tenant

Street Name:


County: Antrim Ards Armagh Bedfordshire Berkshire Belfast Ballymena Ballymoney Banbridge Ballymoney Borders Region Bristol Buckinghamshire Cambridgeshire Central region Carrickfergus Craigavon Cheshire Channel Is Cookstown Coleraine Clwyd Cornwall Castlereagh Cumbria Dumfries and Galloway Region Derbyshire Devon Dungannon Dorset Down Derry Durham Dyfed East Riding of Yorkshire East Sussex Essex Fermanagh Fife Region Gloucestershire Grampian Region Greater London Greater Manchester Gwent Gwynedd Hampshire Hertfordshire Herefordshire Highland Region Isle of Man Isles of Scilly Isle of Whight Kent Lancashire Leicestershire Linconlshire Limavady Londonderry Lothian Region Larne Lisburn Mid Glamorgan Middlesex Merseyside Magherafelt Moyle North Yorkshire North Down Northamponshire Norfolk Nottinghamshire Newtownabbey Northumberland Newry amd Mourne Omagh Orkney Is Oxfordshire Powys Rutland South Glamorgan Shetland Is Shropshire Somerset Staffordshire Strabane Strathclyde Region Suffolk Surrey South Yorkshire Tyne and Wear Tayside Region Tyrone West Glamorgan Western Isles West Sussex Warwickshire Wiltshire Worcestershire West Midlands West Yorkshire

Post Code:


Time at Current Address: Less than 1 month 1 month 2 months 3 months 4 to 6 months 7 months to 1 year 1 year to 2 years More than 2 years

Primary Income
Full-Time Employment Part-Time Employment Self-Employment Temporary Employment Pension Unemployed Disability Benefits

Monthly Pay (after tax):

Next Pay Date:
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 2010 2011

Employer Name


Pay Frequency: Last working day of month Weekly Four weekly Biweekly Twice monthly Specific day of month Last Monday of month Last Tuesday of month Last Wednesday of month Last Thursday of month Last Friday of month Specific Date

Following Pay Date:
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 2010 2011

Time With Employer
Less than 1 month 1 month 2 months 3 months 4 to 6 months 7 months to 1 year 1 year to 2 years 2 years to 4 years 4 years to 8 years Over 8 Years

Paid into Bank Account: Yes, UK Account Yes, Other Account No

National Insurance Number:

I have read and am happy with the loan conditions and am happy that as a condition of credit

I understand that lenders may use credit reference and fraud prevention agencies to make lending decisions and for the prevention of fraud and money laundering.

Please note: You must confirm this before continuing with your loan application

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