[firmName], [firmTown], [firmCounty] Mortgage Intermediary

full name		full name
date of birth		date of birth
marital status		marital status
home no/name		home no/name
street		street
town/city		town/city
postcode		postcode
time at address		time at address
daytime tel		daytime tel
evening tel		evening tel
email address		email address
residential status		residential status
on electoral register		on electoral register
employment status		employment status
gross annual earnings		gross annual earnings
loans/credit cards outstanding		loans/credit cards outstanding

type of enquiry
purchase prce/approximate value of property to be bought/remortgaged		£
amount of mortgage required and type		£
term and rate preferred		yrs
existing mortgage lender (if any)
other information or comments (e.g. arrears, ccjs, guarantors etc.)


[firmName] [address1] [address2] [firmTown] [firmCounty] [postcode]
Location Map	Directions
tel: [phoneStd] [phoneNumber] fax: [faxStd] [faxNumber] [enquries]@[domainName] Registration Address: As Above Registration Number:[regNumber]
Partner's Names [partnersNames]
Other Names [otherNames]

[firmName] is Authorised and Regulated by the Financial Services Authority. is entered on the FSA register (www.fsa.gov.uk/register/) under reference