APPLICANT: INTRODUCTORY AGENT (If Applicable) Name: Address:   Email Telephone:   Fax No. Name: Company: Address: Tel No. Fax No. A. What is the purpose of the mortgage? B. How much does the Applicant want to borrow? £ Over Years C. What security is offered for the advance? Address Freehold/Leasehold Please Choose Freehold Leasehold If leasehold, years unexpired Current Market Value £ D. Is the property or business to be purchased by Applicant? If so, please complete the following : Purchase Price £ Applicants contribution Source of Applicants contribution Does purchase price include goodwill, fixtures and fittings? Yes No E. If the answer to question 'A' is 'refinance', please complete the following: Name of existing lender(s)? Amount outstanding £ Date property purchased Purchase Price £ F. Is the Applicant's ability to service the borrowing to be evidenced by - Please Choose - Accounts Projections Verifiable Income Self Certification Other - Please specify Other G. Is there any further information that may help us? Additional Securities (Type, Value) Additional Income (Amount, Source) Any Adverse Information ?