1. Your details

Title select Mr Miss Mrs Ms

First name *

Last name *

Email address *

House number *

Postcode *

2. Contact telephone details

We will aim to contact you within 24 hours of receiving this form

Best time to contact select morning afternoon evening

Best telephone contact number *

3. Your employment status

Please select how you are best described select full time part time self-employed other

4. Your finances

Please select how you own your home select property with a mortgage property outright

How much do you think your property is worth? select less than £40,000 £40,000 - £150,000 £150,000- £300,000 more than £300,000

What is your total household income? select under £20,000 £20,000 - £30,000 more than £30,000

How much is your mortgage a month?

How much would you like to borrow? With Regency Direct you can borrow from £7,500 to £250,000

What are you borrowing the money for? select home improvement debt consolidation car purchase other

How did you find the website? select TV ad direct mail search engine web banner Spring Clean 2008

This information may be used by Regency to inform you of other products or services. Remove the tick if you do not wish to receive such information.

Please enter the validation code below in order to verify your request

A Regency Direct loan is secured on your home.

THINK CAREFULLY BEFORE SECURING OTHER DEBTS AGAINST YOUR HOME.  YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON A MORTGAGE OR ANY OTHER DEBT SECURED ON IT.

Any details you supply will be processed under the principles of the Data Protection Act 1998.  We may pass your details to another broker in order to process your application.

Regency Direct Ltd
Registered in England and Wales:
Suite 8, Bourne Gate, 25 Bourne Valley Road, Poole, Dorset BH12 1DY
Registered number: 5455842
homeowner-loans@rmcgroup.co.uk

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