Title:

Surname:

Previous Surname (If Applicable):

Forenames:

Date of Birth:

Telephone Number:

Email:

Number of Dependable Children:

Marital Status: Married/CohabitingSingleWidowedDivorced

Current Address:

Time at Address:

Please select one of the following: HomeownerTenantLiving with parents

Previous address if less than 3 years:

Employment Information

Occupation:

Employment Status:EmployedSelf-employed

Employment Hours: Full TimePart Time

Type of Employment Contract: PermanentTemporary

Name of Employer:

Employer Telephone Number:

Time with Employer

Employer's Address:

Affordability

Does the agreement replace an existing finance loan that will be repaid as a result of this agreement? Yes No

Gross annual income (£):

Your share of monthly mortgage/rental expenditure? (£)

Other material monthly expenditure that is not debt related such as school/university fees or maintenance etc. (£)

Are there any expected changes in your personal circumstances that would result in you being unable to repay the loan over the term of the agreement? ( for example, being unable to pay the full monthly installments due to retirement, redundancy, reduction in working hours/salary, career change or change in family circumstances.) Yes No

If delivery does not take place within 90 days, we will need to reassess your application, This will involve your supplying dealer checking with you whether there has been any change to your responses to these questions.

For security reasons, we will contact you upon submission of this form regarding any other confidential information that we require and to request your bank details in order to help us process your application.

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