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Personal Details Title - - - - Please Select - - - - Mr. Mrs. Miss. Ms. Dr. Surname / family name First name(s) Date Of Birth Your Partner's Personal Details (if applicable) Partner's title - - - - Please Select - - - - Mr. Mrs. Miss. Ms. Dr. Surname / family name First names Date of birth Your Address and Contact Details House name / number and street Area or suburb Town or city Postcode Daytime telephone number Evening telephone number Mobile telephone (if any) Email address * Your Employment and Income Details What is the nature of your employment? - - - - Please Select - - - - Employed Self Employed Retired Houseperson Not working What is your gross annual salary £ Additional annual overtime/bonuses £ Your Partner's Employment and Income Details (if applicable) What is your partner's employment? - - - - Please Select - - - - Employed Self Employed Retired Houseperson Not working What is their gross annual salary £ Additional annual overtime/bonuses £ Your Residential Details What is your residential status? - - - - Please Select - - - - Homeowner Renting Living with Family/Friends If you are a homeowner or mortgage payer, please give further details: What is the estimated property value £ What is your current mortgage balance £ Who is your current mortgage lender? What interest rate are you currently on? % About Your Monthly Expenditure What is your monthly mortgage or rent payment (£) £ How much do you owe on credit or store cards (total) £ What is the total monthly payment for your cards £ How much do you owe on other loans or credit £ What is the total monthly payment for other credit £ About Your Credit History Have you received a CCJ or default in the last 6 years? No Yes Have you ever been declared bankrupt? No Yes Have you missed a mortgage payment in the last 12 months? No Yes Have you missed any other payments in the last 12 months? No Yes Your New Mortgage Requirements What is the purchase price or valuation £ Have you found a property yet? Yes No Do you have a deposit available ? Yes No How much would you like to borrow £ What term do you require? (years) Do you need to certify your own income? Yes No What type of mortgage do you require? - - - - Please Select - - - - Fixed Capped Tracker Offset Don't Know When would you like to complete? - - - - Please Select - - - - Within 8 weeks Unknown date Your Insurance Requirements Would you like a quote for Life Insurance or Income Protection? Yes No   Would you like a quote for accident, sickness & unemployment cover? Yes No Would you like a quote for buildings insurance? Yes No Would you like a quote for home contents insurance? Yes No Further Details Please use the following space to add any further information you feel relevant to your enquiry: By submitting this enquiry form I understand that I am under no obligation, I may cancel this enquiry at any time with no penalties or costs due and that no credit check will be performed without my permission.

Your home may be repossessed if you do not keep up repayments on a mortgage or any other debt secured on it.

Shire Financial Management (Independent Mortgage Advisers) LLP is authorised and regulated by the Financial Services Authority number 301835. You can check this on the FSA's Register by clicking here and inserting our FSA number 301835. Buy to let mortgages and secured loans are not currently regulated by the FSA. For full details on any schemes or products shown or referred to, please call one of our advisors on 0845 459 8801. Actual rates available will depend upon your circumstances. Please ask for a personalised illustration