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Full Name:
Have you been known by any other names: NoYes [group OtherNames]
Please enter your previous Full Name: [/group]
Date of Birth:
Email:
Mobile Phone Number:
Home Phone Number:
Residential Status: —Please choose an option—HomeownerHomeowner (Mortgaged)Rented (Private)Rented (Council or Housing Association)Living with ParentsOther (Please specify)
[group ResidentialStatusSpecifyOther] Please specify your current residential status: [/group]
Employment Status: —Please choose an option—Employed - (full-time)Employed - (part-time)Self-employedStudentUnemployed
[group EmployerInformation]
Time in Employment:
Years:
Months:
Employer Name:
Employer Phone Number:
Employer Address: [/group]
Building name or Number:
Street Address 1:
Street Address 2:
Town/City:
County:
Post Code:
Have you changed your address in the last 5 years?
NoYes
[group PreviousAddress1] Previous Address 1:
Add additional previous address [/group]
[group PreviousAddress2] Previous Address 2:
[group PreviousAddress3] Previous Address 3:
[group PreviousAddress4] Previous Address 4:
[/group]
Product name:
Please give the name of the product you would like to use monthly payments for.
Product price:
Total amount of months requested:
The following information will be used to help calculate the affordability of your purchase. If the field is not applicable to you please just leave it blank.
All fields are Per Month.
Rent or Mortgage Payments
Council Tax
Utilities (Gas, Electric)
TV, Phone & Broadband
Insurance
Travel Expenses
Child Care
Food and Groceries
Loan & Credit Card Repayments
Other (Any monthly costs not included in this list)
By proceeding with this application I understand and consent to the use of Credit Reference and Fraud Protection agencies being used to assist with decision making.
The information I have provided is a true reflection of my income and expenditure.
I agree to supply further information as required or understand that the application may not be able to progress.
I agree to supply proof of address and ID such as a driving licence or passport upon request.
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