application form

	1. Your details Title select Mr Miss Mrs Ms First name * Last name * Email address * House number * Postcode * 2. Contact telephone details We will 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. close window