Introducers Registration Form

Title:
Mr Mrs Ms Miss

* Name:

* Company:

Business Classification:
IFA Mortgage Consultant Accountant Solicitor

* Address:

* Postcode:

* Telephone:

Fax:

* Email:

Are you Directly Regulated or a network member?
Directly Regulated Network Member

Member of which network (if applicable):

Have you already applied to advise on Lifetime Mortgages since 31/10/04:
Yes No

If Yes - was it through FSA or through your network:
FSA Network

To help us allocate sufficient resources please answer the following:

How many Equity Release cases have you arranged in the last 12 months?
0 1-3 4-6 7-10 11+

Now being able to refer cases, how many do you think that you may refer to us in the next 12 months?
0 1-3 4-6 7-10 11+

To avoid any unintentional cross selling please indicate which of the following you are unable to advise on and would therefore still be happy for us to handle for your client:

Ordinary mortgages (Please note that where an interest only mortgage is deemed best advice - to avoid wasted time we will reserve the right to arrange this)

Investments

Long Term Care

Regulated Life Insurance

The Equity Release Bureau would like to keep you informed by post/phone or e-mail. If you would prefer not to be contacted please tick the box.

Title:
Mr Mrs Ms Miss

* Name:

* Telephone:

* Date Of Birth (mm/dd/yyyy):

Please confirm that you have read the points to consider and our Data Protection Statement before submitting this form.