Please complete the form as fully as possible and click on “send form” at the bottom of the page
Fields marked * are required
how did you hear about us?:
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Affiliated Loans
Doyle's
Existing customer
Fee Free Loans
Freeserve Banner
Highfield
HSFS
Internet Banner/Advert
Internet Search Engine
Parliament Finance
Recommended
South Coast Finance
Swift Loans
Touch
Yell.com Directory
Yellow Pages
if Internet Search Engine - which one?:
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Altavista
Ask Jeeves
BBCi
Delv
Excite
Freeserve
Google
K-Media
Lycos
MSN
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Yell.Com
Other
Loan Details
How much would you like to borrow?
Over what time period?
12 months
18 months
24 months
30 months
36 months
42 months
48 months
Purpose of loan?
What sort of application are you making?
Main Applicant
title:
first name :
middle name(s):
surname:
date of birth
(dd/mm/yy) *
marital status:
Please select
Married
Single
Living with partner
Separated
Divorced
number of children under 18:
Please select
None
One
Two
Three
Four
Five
Six
occupation:
employment type? :
Please select
Full time
Part time
Self employed
Agency
how long in current employment?:
name of employer:
(no contact made)
location of employer:
monthly net take home pay £:
residential status:
Please select
Homeowner
Private tenant
Council tenant
Housing Association
Tenant (other)
Lodger
Living with parents
Living in partner's house
if homeowner - value of property £:
if homeowner - size of mortgage £:
Main Applicant contact telephone numbers & email:
home:
work:
mobile:
preferred contact no:
Please select
home number
work number
mobile number
email address:
Spouse or partner (if applicable)
title:
first name :
middle name(s) (if applicable):
surname:
date of birth:
(dd/mm/yy)
marital status:
Please select
Married
Single
Living with partner
Separated
Divorced
occupation :
employment type? :
Please select
Full time
Part time
Self employed
Agency
how long in current employment?:
name of employer:
(no contact made)
location of employer:
monthly net take home pay £:
residential status:
Please select
Homeowner
Private tenant
Council tenant
Housing Association
Tenant (other)
Lodger
Living with parents
Living in partner's house
if homeowner - value of property £:
if homeowner - size of mortgage £:
Spouse or partner's contact telephone numbers & email:
work:
mobile:
email address:
Addresses over last 5 years
current address
line 1:
line 2:
post code:
how long in occupancy?:
Please select
< 6 months
6 - 12 months
1 - 2 years
2 - 3 years
3 - 4 years
4 - 5 years
5 - 6 years
6 - 7 years
7 - 8 years
8 - 9 years
9 - 10 years
> 10 years
previous address 1
line 1:
line 2:
post code:
how long in occupancy?:
Please select
< 6 months
6 - 12 months
1 - 2 years
2 - 3 years
3 - 4 years
4 - 5 years
5 - 6 years
6 - 7 years
7 - 8 years
8 - 9 years
9 - 10 years
> 10 years
previous address 2
line 1:
line 2:
post code:
how long in occupancy?:
Please select
< 6 months
6 - 12 months
1 - 2 years
2 - 3 years
3 - 4 years
4 - 5 years
5 - 6 years
6 - 7 years
7 - 8 years
8 - 9 years
9 - 10 years
> 10 years
Largest monthly financial outgoings: please list with approximate amounts
examples : rent, mortgage, car loan, personal loan, credit cards, bank overdraft, debt arrangements etc
1.
2.
3.
4:
Credit history
note: voluntary disclosure of adverse history, such as CCJs, will enable us to treat your application sympathetically
Main Applicant
have you had any CCJs in the last 6 years? :
Please select
Yes
No
if yes - please give full details
Spouse or Partner
have you had any CCJs in the last 6 years? :
Please select
Yes
No
if yes - please give full details
You agree that Burtplan may search for information about you with credit reference agencies who will record details of the search. If you borrow, details of how you conduct your account (including going into default) may be disclosed to the agencies. Any information provided to Burtplan or others may be used for making credit decisions regarding you, members of your household or others to whom you are linked financially. Information may also be used for debt tracing, fraud prevention and the prevention of money laundering. If you are making a joint application in the absence of the other party or if you state a financial association with another person, you are declaring that you are entitled to disclose information about him or her and to authorise Burtplan to search, link and record information about you and anyone referred to by you, with credit reference agencies. This application may be assessed with reference to records of other people with whom you are linked financially. You have a right to be told which credit reference agencies Burtplan has used and a right to obtain a copy of your credit file.
