Title:

Select... Mr Mrs Ms Miss

First name:

Surname:

How old are you:

Select... Under 21 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 55 Over 55

Date Of Birth:

Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944

Marital Status:

Select... Married Single Living With Partner Widowed Divorced/Seperated

Daytime phone number:

Alternative phone number (Mobile):

E-mail address:

Address:

Town/City:

County:

Postcode:

What is your residential status?

Select... Home Owner Living With Parents Council Tenant Tenant Furnished Tenant Unfurnished

Do you have a credit card?

Select... yes no

Are you on the electoral roll?

Select... Yes No

Do you have any CCJs?

Select... yes no

How long have you been in your job?

Select... Employed - Less 6 Months Employed - 7 Months - 2 Years Employed - 2 Years - 5 Years Employed - Over 5 Years Part-Time Retired Self Employed Unemployed

Do you have any Defaults?

Select... yes no

How long have you been with your current bank?

Select... less than 6 months 7 mts - 2 yrs 2 yrs - 5 yrs 5 yrs - 10 yrs 10 yrs + no bank account

Have you ever been declared a bankrupt?

Select... yes no

What is your current financial
situation?

Select... Never missed a payment Sometimes pay late Sometimes misses payments In arrears with one lender Several payments in arrears No credit agreements

How much debt do you have?

£ Enter approx total value
eg. £12,000.00

Do you have a Cheque Guarantee card?

Select... yes no

How many companies do you owe money to?

Select 1 2 3+

Why did you visit this site?

Select... Ive got debt problems I need help to get out of debt I would like info about debt solutions Ive been refused credit I'm worried about credit I want to apply for a mortgage I want to apply for a personal loan I want to apply for a secured loan I want to apply for a credit card I want to apply for car finance Just general interest

How did you hear about us?

Select... recd an email Newspaper Google Yahoo Other Search Engine Word Of Mouth Direct Mail in the Post Other