Introducer KFI Request

Form Sent Confirmation Application Type: * Single Joint

First Applicant Title: * Please select... Mr Mrs Miss Ms Captain Colonel Doctor Father General Lady Lieutenant Major Professor Reverend Sergeant Forename(s): * Surname: *

Second Applicant Title: Please select... Mr Mrs Miss Ms Captain Colonel Doctor Father General Lady Lieutenant Major Professor Reverend Sergeant Forename(s): Surname:

Loan Description: * Purchase Remortgage

Purchase Price/Valuation (£): *

Mortgage Loan Amount (£): *

Term (Years): * Please select a term... 5678910111213141516171819202122232425262728293031323334353637383940

Expected Completion Date: -- 12345678910111213141516171819202122232425262728293031 Expected Completion Date: -- 123456789101112 Date of birth of Beneficial Owner: ---- 20092010

Product: * Please select a product....    Exclusive Product (enter details below)    Portability Product (enter details below)

Exclusive/Portability Product Details: (If applicable)

Add Product Arrangement Fee to the loan?: * No Yes

(If not added, the fee will be collected up front on receipt of the application)

Payment Method: * Repayment Interest Only Part Repayment & Part Interest Only

If you have selected ‘Part Repayment & Part Interest Only’ then please enter a monthly ‘Interest Only’ payment amount below:

Interest Only Amount (£):

FSA Firm Reference: *

Company Name: *

Contact Name: *

Street Address: *

Town: *

County: *

Postcode: *

Telephone Number (including STD): *

Email Address: *

Member of Mortgage Club/Network?: * No Yes

If applicable, through which mortgage club/network do you wish to submit this case?

Submit Case Through: -- John Charcol London and Country Legal and General Mortgage Club Mortgage Intelligence Personal Touch Financial Services Portfoleo Premier Mortgage Service Simplybiz Mortgages The Mortgage Times Group Ltd Other

Amount of Procuration Fee (£):

Do you charge a fee for arranging this mortgage?: * No Yes

If there is a fee to pay, please complete the details below:

When Paid?: -- Completion Application Post Completion

Fee Amount (£):

Is the fee refundable?: -- Fully Refundable Partly Refundable Non Refundable

Submission of Details