Commercial Mortgage Application Form by yu3413



Effective 1st August 2006

       Section 1 -         THE APPLICANTS

       Section 2 -         PERSONAL DETAILS

       Section 3 -         PERSONAL INCOME DETAILS

       Section 4 -         FINANCIAL DETAILS

       Section 5 -         BUSINESS DETAILS

       Section 6 -         THE PROPERTY

       Section 7 -         THE LOAN

       Section 8 -         INSURANCE

       Section 9 -         VALUATION

       Section 10 -        DIRECT DEBIT

       Section 11 -        DECLARATION

       Section 12 -        DOCUMENTATION REQUIRED


.   Please complete this Application Form in ink and write in BLOCK CAPITALS. All
    sections must be completed. Failure to do so will result in a delay with the processing
    of your application.

.   Please complete sections 1 to 12.

.   Please remember to complete the Direct Debit form (Section 10), read and sign the
    Declaration (Section 11). Failure to do so will result in a delay with the processing of
    your application.

.   Please remember to include your cheque for the payment of fees if you are paying by
    this method. Please make your cheque payable to ‘Monmouthshire Building Society’.

.   If you are sending any original documents by post, please make sure they are securely

    packaged and sent via Recorded or Registered post.


    - For Employed applicants: Your last three payslips and P60 must accompany the

    - For Self-Employed applicants: Last two years certified accounts must accompany

    the application.

    If you need additional space to answer any of the questions, please use the space on

    page 12.

    If you need help in completing this application form, contact us on 01633 844 444
    or speak to your mortgage intermediary.

    Thank you for choosing the Monmouthshire Building Society.

    Head office: Monmouthshire House, John Frost Square, Newport, South Wales. NP20 1PX. T: 01633 844 444   F: 01633 844 445   DX: 33240

    Company Name

                                                                                            Full Name
                                                                                            Telephone No.

                                                                                            Fax No.

                                                                                            Email Address

    TO BE COMPLETED IN ALL CASES - I Confirm that:
                I am authorised and regulated by the Financial Services Authority - (Please list all numbers)

                                                                                      Society use, checked by:

    I confirm that less than 40% of the property will be occupied by me or any close relative on a residential basis.
    PLEASE NOTE: The Society does not provide regulated commercial loans. If the applicant or any close relative occupies 40% or more of the property on
    a residential basis the Society will not be able to assist.

     If terms have been discussed and agreed by the Society, please state with whom, the date and give details of the agreement

    MONEY LAUNDERING - To be completed by a regulated UK intermediary
    Was the verification taken:             Face to face                 or       Non face to face

    Applicant’s Identification                                         Applicant 1                                           Applicant 2 / Guarantor

    Evidence of Name

    Type of Name verification provided

    Document Reference

    Issuing office/organisation

    Place and date of birth

    Issue and expiry dates

    Evidence of Address

    Type of Address verification provided

    Document Reference

    Issuing office/organisation

    Issue and expiry dates

    If non face to face - additional identity check needs to be undertaken (either name or address): A signed personal cheque is sufficient additional evidence of name.

    Type of verification provided

    Document Reference

    Issuing office/organisation

    Issue and expiry dates

    I confirm I have seen the original documents; checked that any requiring a signature were pre-signed; and that any associated photograph bore a good likeness to the applicant

    Full name

    Signed*                                                                                                      Date

    * Note that this certificate must be signed by the person who has seen the original documentary evidence

      Section 1 - THE APPLICANTS

      Daytime contact and telephone number                               Address for correspondence


       Tel. No.

      Individuals and Partnerships should complete Section 1.2

      Company Applicants proceed to Section 1.3


1.2   Individuals and Partnerships to complete
                                                  Forename(s) in full            Surname                      Joint Applicant(s)
                                                                                                        State relationship to first applicant
                                                                                                        e.g. spouse, business partner etc

        1st Applicant     Mr/Mrs/Miss/Ms

        2nd Applicant     Mr/Mrs/Miss/Ms

        (if applicable)

1.3   Limited Company Applicants

      Company’s full registered name and address                        Company Registration Number

                                                                        Date of Incorporation


                                            Forename(s) in full                   Surname                                 % Shareholding







          Note: The first applicant will be the first named in the Society’s records in respect of the mortgage. Only the first applicant will be entitled to voting rights in
          respect to the mortgage subject to being a Borrowing Member. Please note that Bodies Corporate cannot be Borrowing Members.

                                                                  APPLICANT 1                                                      APPLICANT 2 / GUARANTOR
    2.1   Surname

    2.2   Forenames

    2.3   Title                         Mr             Mrs        Miss            Ms       Other                  Mr             Mrs         Miss            Ms      Other

    2.4   Marital Status

    2.5   Nationality

    2.6   Date of Birth

    2.7   Previous names (last 3 years)

    2.8   Email Address

    2.9   Telephone Number                   Day                                                                       Day

                                             Mobile                                                                    Mobile

                                             Evening                                                                   Evening

    2.10 Number of dependants                No.                         Age(s)                                        No.                          Age(s)
         and their ages

    2.11 Present Address

          If at this address for less
          than 2 years please
          provide previous
          addresses on page 12

                                                                   Post Code                                                                 Post Code

    2.12 How long have you
         lived at this address?                                    Years                   Months                                            Years                   Months

    2.13 Basis of Occupation                 Owned outright                                                            Owned outright

                                             Owned subject to mortgage                                                 Owned subject to mortgage

                                             Rented                                                                    Rented

                                             With Parents / Relatives / Other                      Please state        With Parents / Relatives / Other                      Please state

    2.14 Lender’s / Landlord’s Name

    2.15 Lender’s / Landlord’s

          If you currently have a
          mortgage your lenders
          most recent statement
          must accompany the

                                                                   Post Code                                                                 Post Code

    2.16 Loan / Rent Account No.

    2.17 Monthly Payment / Rent               £                                                                         £

    2.18 Approximate balance
         outstanding (Mortgage only) £                                                                                  £

    2.19 Sale Price / Value                   £                                                                         £


                                                            APPLICANT 1                                                   APPLICANT 2 / GUARANTOR

3.1   Occupation

3.2   Basis                         Employee              Self Employed                                     Employee               Self Employed

                                     Director            - Please state % shareholding                  %     Director            - Please state % shareholding                  %

3.3   Anticipated retirement age                 Years                                                                    Years

                                    If Self-Employed proceed to question 3.11                                If Self-Employed proceed to question 3.11

EMPLOYEE / DIRECTORS -                        Last three months payslips and latest P60 must accompany the application

                                                            APPLICANT 1                                                   APPLICANT 2 / GUARANTOR

3.4   Employer’s Name

3.5   Employer’s Address

                                                              Post Code                                                               Post Code

                                   Tel. No.                                                                 Tel. No.

                                   Payroll No.                                                              Payroll No.

      Is your Employment:          Permanent             Fixed term contract                   Months       Permanent             Fixed term contract                   Months
                                   Other                                                                     Other
                                                                                         Please state                                                             Please state

3.6   Length of Employment                                    Years                      Months                                        Years                      Months

      If in current employment for less than 6 months please give details of previous employment using the space on page 12

3.7   Annual Basic Salary
                                    £                                      Per annum                                 £                                   Per annum
      (before tax)

3.8   Overtime / Commission         £                                      Per annum                                 £                                   Per annum

3.9   Other Pay                     £                                      Per annum                                 £                                   Per annum
      (e.g. Shift Allowance)

                               Total £                                     Per annum                        Total    £                                   Per annum

3.10 Other Income.                   SOURCE:                              AMOUNT:                           SOURCE:                              AMOUNT:
     e.g. pension, rents,
     maintenance etc.
                                                                          £                    Per annum                                          £                  Per annum

                                                                          £                    Per annum                                          £                  Per annum

                                                                          £                    Per annum                                          £                  Per annum

    SELF-EMPLOYED -                Two years certified accounts must accompany the application

                                                              APPLICANT 1                                                APPLICANT 2 / GUARANTOR
    3.11 Name of Business

    3.12 Business Address

                                                               Post Code                                                             Post Code

                                           Tel. No.                                                          Tel. No.

    3.13 How long have you been trading?                        Years                     Months                                    Years                         Months

                                                                                    Year Ended                                                                Year Ended

    3.14 Taxable income /              Last year       £                                     /               Last year       £                                        /
         net profit last 2 years
                                       Previous year   £                                     /               Previous year   £                                         /

    3.15 Accountant’s Name

    3.16 Accountant’s Address

                                                               Post Code                                                             Post Code

                                           Tel. No.                                                          Tel. No.

    3.17 Other Income.                     SOURCE:                         AMOUNT:                           SOURCE:                           AMOUNT:
         e.g. pension, rents,

         maintenance etc.                                                  £                     Per annum                                       £                    Per annum

                                                                           £                     Per annum                                       £                    Per annum

                                                                           £                     Per annum                                       £                    Per annum

        Section 4 - FINANCIAL DETAILS

    4.1 Please give details of any substantial expenditure calculated on a monthly basis
        Please indicate if any of your outstanding credit commitments will be repaid on completion of your new mortgage.

                                                                  APPLICANT 1                                                APPLICANT 2 / GUARANTOR
                                                             Amount        To be          Monthly                                 Amount             To be          Monthly
                                                            Outstanding    repaid       repayments                               Outstanding         repaid       repayments
         Loans/credit card payments                     £                           £                                        £                                £

         Bank overdrafts                                £                           £                                        £                                £

         Hire purchase                                  £                           £                                        £                                £

         Mortgage/secured loans                         £                           £                                        £                                £

         Maintenance payments                                                       £                                                                         £

         Sundries (eg. School fees etc.)                                            £                                                                         £


      Have you ever been in arrears with any credit agreement, including your
                                                                                       Yes          No                                                Yes          No
      mortgage or rent, voluntarily/involuntarily given up possession of your home,
      or had your home repossessed by a lender?

      Have you ever defaulted on a loan or had a judgment or court order made          Yes          No                                                Yes          No
      against you or, if self-employed, your business?

      Have you ever been declared bankrupt or made any arrangements with               Yes          No                                                Yes          No

      Have you been involved in any court proceedings for debt or ever                 Yes          No                                                Yes          No
      been convicted for theft, fraud, robbery or any other criminal offence
      (other than a motoring offence)?
                                                                                        If Yes to any of the above, please give details in the space at the back of this form.

      Might your income or expenditure change significantly in the near future?               Yes          No

      Do you anticipate moving or any other significant changes in the foreseeable future?    Yes          No

      if you have answered YES to either question, please provide full details


5.1 What is the nature of your buisiness?

5.2 How long has it been established?

5.3 How long has it been established?

5.4 Name and address of your accountant:

                                                               Post Code

5.5 How long has he/she acted for you?
                                                                                                                 Account No.              Approx. balance        Credit/
5.6 Name and address of your
    business bank account:

                                                              Post Code                                  Please enclose a copy of your last statement

5.7 Does the business have any other borrowing outstanding? If so, please give details:

                                                                                       Account                        Amount              Monthly              Final
      Name and address of lender and account number                                    number                       outstanding          repayment          payment date

.         Section 6 - THE PROPERTY

    6.01 Address

                                                                        Post Code

    6.02 Tenure:             Freehold                  Leasehold   Term of lease    Years   Please state the age of the property   Years

    6.03 State type of lease together with the annual
         rental/maintenance charge payable:

    6.04 Type of construction:

    6.05 Please give full details of the present and the
         proposed use of the property:

    6.06 If any of the property is or will be let, please
         provide details of the type and term of the
         lease/s and the income receivable:

    6.07 Name and address of the present owner, or
         builder if under construction:

    6.08 Name, address and telephone number of
         selling agent or the person who can arrange
         access for the Society’s valuer:

    6.9    Name, address and telephone number of
           your Solicitor:

.   Section 7 - THE LOAN

7.01 How much do you want to borrow?           £                                          7.04 Repayment term

7.02 Purchase price (‘bricks and mortar’ -                                                7.05 If remortgaging, or buying as a sitting
     excluding goodwill, stock and trade,      £                                               tenant, your estimate of the present       £
     fixtures and fittings):                                                                   value (bricks and mortar) is:

7.03 Cost of improvements/alterations you
                                               £                                          7.06 Date purchased if already owned?                   /         /
     intend to make (if applicable):

7.07 Are you borrowing any of the difference between this loan and the purchase price?
     If yes, please provide full details:                                                    Yes            No

7.08 Purpose of the loan? (Please explain as fully as possible)

7.09 Repayment type and amount

     Type(s) and amount(s) of Loan required:

                       Repayment       £                                                 Pension            £

                       Investment      £                                                  Interest Only     £

7.09 If you have selected an investment or pension linked loan, please give details of the policy(ies) / schemes which are intended to repay the capital.
     (Please use the space at the back of this form if necessary)
                                                         1                                              2                                          3


      Type of Policy

     Life/Lives Assured

      Policy Number

      Life cover                £                                                £                                           £

      Start Date

      Maturity Date

      Monthly Premium           £                                                £                                           £

7.10 Do you have sufficient life assurance to cover the mortgage?               Yes            No

7.11 If NO, we would strongly recommend that you review your position.
     Would you like one of our qualified representatives to contact you?        Yes            No

.     Section 8 - INSURANCE

    Please note that the insurance must be acceptable to Monmouthshire Building Society.

    8.01 Insurance provider:

    8.02 Amount of cover:             £                                       8.03 Monthly premium:               £

    8.04 Insurance commences:             \      \                            8.05 Renewal Date:                      \   \

         As a condition of any loan, the Society will insist that the property is fully insured against all normal risks. Appropriate cover must be in force and details supplied
         to the Society prior to the completion of the loan.

    8.06 Would you like the Society to arrange
         insurance cover?                                    Yes            No

    8.07 Do you wish the Society to arrange
         quotations?                                         Yes            No

      Section 9 - VALUATION

         The Society is required by law to obtain a professional valuation of any property forming security for a loan. The Valuer's inspection will be limited and the report
         produced purely for the purposes of the Society in deciding whether or not to grant the loan requested. The Society or its Valuer accepts no responsibility for the
         accuracy of validity of any statements or opinions made or implied in the Valuation Report. You must not rely on this report in deciding whether or not to purchase
         and you are strongly advised to obtain a more comprehensive inspection and report, before entering into a contract of purchase.

         The appropriate Valuation fee must be paid to the Society before the application can proceed. You will be advised of the amount payable when the application is
         submitted. Valuation fees may only be refunded if the application is cancelled before the valuer has been instructed.

    8.06 Do you require a more detailed inspection and report? (Buy to Let only)               Yes           No

         Additional security (if available):

    8.07 Address:


    8.08 Descrition of property:

    8.09 Date purchased                   \      \

    8.10 Estimated value:             £

    8.11 Existing mortgagee

    8.12 Balance o/s                  £

    8.13 Arrears                      £

    8.14 Tenure:                                            Freehold                    Leasehold               Title number (if known)

.  Section 10 - DIRECT DEBIT (This section MUST be completed)

    Instruction to your Bank or Building Society to pay by Direct Debit

1 - Name and full postal address of your Bank or Building Society
    To: The Manager                       Bank/Building Society                   Originator’s Identification Number

    Address                                                                         9        4        1        2        6       7
                                                                                  Reference Number (office use only)

                                          Postcode                                 8 0 0 1 -

                                                                            5-    (This is not part of the instruction to your Bank or Building Society)

2 - Name(s) of Account Holder(s)                                                  Preferred Payment Date (insert day between 1 and 28)
                                                                                  I/We wish to pay monthly on                        or just after this date.

                                                                             6-   Instruction to your Bank or Building Society
3 - Bank/Building Society account number                                          Please pay Monmouthshire Building Society Direct Debits from the account
                                                                                  detailed in this Instruction subject to the safeguards assured by the Direct Debit
                                                                                  I understand that this Instruction may remain with Monmouthshire Building Society
                                                                                  and, if so, details will be passed electronically to my Bank/Building Society.
4 - Branch Sort Code


   Please fill in the whole form using a ball point pen and return it to:
   Monmouthshire Building Society, Monmouthshire House, John Frost
   Square, Newport, South Wales, NP20 1PX.                                        Date

                              Banks and Building Societies may not accept Direct Debit Instructions for some types of account

                                                                            Head Office:
                                                             Monmouthshire House, John Frost Square,
                                                                 Newport NP20 1PX, South Wales.
                                                               Tel: 01633 844444 Fax: 01633 844445
                                                                             DX: 33240

                                                      The Direct Debit Guarantee
                           This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme. The
                           efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society.

                           If the amounts to be paid or the payment dates change Monmouthshire Building Society will notify you within
                           10 working days in advance of your account being debited or as otherwise agreed.

                           If an error is made by Monmouthshire Building Society or your Bank or Building Society, you are guaranteed a
                           full and immediate refund from your branch of the amount paid.

                           You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy
                           of your letter to us.

.    Section 11 - DECLARATION

                                                                PLEASE READ CAREFULLY AND SIGN

          In applying for this loan on the security described in this application, I declare that
          all the information provided herein is, to the best of my knowledge, accurate and
          complete and, that it will form the basis of any Offer of Advance by the Society and
                                                                                                    13   I consent to the Society making enquiries with any other person or body which it
                                                                                                         considers necessary as part of its assessment and underwriting of this application,
                                                                                                         and I give my consent and instruct such other person or body to give a full and
          any Insurance made by the Society’s insurer’s. I declare that no material                      accurate reply to the Society.
          information relevant to consideration of the proposed loan, or to any insurance
          requested, has been withheld. If I have not personally completed this form, I             14   I consent to the information on this form being passed to any guarantor
          confirm that I have read and checked every answer.                                             of my loan or to his/her legal advisor.
     2    I undertake to notify the Society of any changes in my circumstances e.g.                 15   I authorise the Society to supply a copy of the Offer of Advance and to
          redundancy, change of employment, relationship breakdown, serious illness or                   provide any other information about my application and any subsequent
          injury etc. which arise following the completion of this form.                                 loan advanced by the Society to an insurer, where any general, life or
                                                                                                         pension policy forms part of the loan agreement or any intermediary who
     3    I accept that this application forms the basis of a proposal to an insurance                   submits this application on my behalf if so requested by them.
          company for buildings, contents and Mortgage Payment Protection Insurance
          where I have requested such cover. As such this declaration and consent to use            16   I authorise my solicitor to disclose to the Society all information relevant
          my information will apply to any contract or agreement for services with the                   to the Society’s decision to lend and I waive any right to claim
          insurance company.                                                                             Solicitor/Client confidentiality or legal privilege in respect of such
     4    I have been advised to obtain a fuller inspection and report on the proposed
          property and not to rely solely on the Society’s Valuation Report when deciding           17   I understand that you may disclose information about me, my application
          whether to proceed. If I have not requested a more detailed inspection and report              and any subsequent loan to your external auditors and regulatory bodies
          I accept that the nature of the basic valuation carried out on behalf of the Society           including the Financial Services Authority, Financial Ombudsman
          is not a detailed survey and cannot be relied upon to reveal any faults or defects             Service, agents and service providers.
          which the property may suffer. Neither the valuer nor the Society give any warranty
          that the price/value of the property is either fair, reasonable or accurate. I            18   If I give you false or inaccurate information and you suspect fraud, you
          understand that no responsibility is accepted by the Society or its valuer for any             will record this. You may pass information to organisations involved in
          omissions, conclusions, or the accuracy or validity of any statements or opinions              fraud prevention to protect yourselves and your customers from theft
          made or implied in the valuation report.                                                       and fraud.

     5    I understand that the payment of any fees relating to this application shall not bind     19   In the event of the Society obtaining possession of the property, details
          the Society to making an advance and that such fees are not refunded whether or                will be provided to the Council of Mortgage Lenders Possessions
          not my application is successful.                                                              Register and credit reference agencies. These details may be used by
                                                                                                         other lenders for credit assessment, prevention of fraud or tracing of
     6    I understand that the first named applicant shall be the representative joint                  debtors.
          borrower entitled to exercise the rights of membership.
                                                                                                    20   I/We understand that you will pass the information on this form and
     7    I understand that the Society will keep any commission, fees or allowances which,              about any incident I/we may give details of to IDS Ltd so that they can
          become due to it from insurers.                                                                make it available to other insurers. I/We also understand that, in
                                                                                                         response to any searches you may make in connection with this
     8    I confirm that the deposit towards the purchase price, stamp duty, legal and other             application or any incident I/we have given details of, IDS Ltd may pass
          fees and charges will be provided by me without recourse to additional borrowing               you information it has received from other insurers about other incidents
          unless already known to and agreed in writing with the Society beforehand.                     involving anyone insured under the policy.
          Use of my information                                                                     21   I have a right of access to my personal data held by you and credit and
                                                                                                         fraud agencies. Upon payment of a fee, I can ask for a description of the
     9    I understand that the information I give you will be used by the Society and its               data, the purpose for which it is processed and to whom it may be
          subsidiaries to provide and manage my account, make lending decisions, collect                 disclosed. I also have a right to have data corrected.
          debts, trace debtors and prevent fraud and money laundering. The information
          may also be used by the Society and its subsidiaries for its own use in respect of        22   I understand that you will treat information about me as confidential. You
          business analysis. I understand that all of my records will be updated when I inform           will not share information about me or my account outside the Society
          you of a change to my personal details, unless I advise you otherwise.                         and its subsidiaries for marketing purposes. I understand the Society
                                                                                                         and its subsidiaries would like to contact me by post, telephone or email,
     10   You will make searches about me at credit reference agencies who will supply you               using the contact details which I have provided in this form, to tell me
          with credit information as well as information from the Electoral Register, for the            about it’s financial products, services, promotions, offers and events in
          purpose of verifying my identity. The agencies will record details of the search               relation to investments, mortgages and general insurance which may be
          whether or not this application proceeds. Credit searches and other information                of interest to me. By signing and returning this application I agree to my
          which is provided to you and/or the credit reference agencies, about me and those              information being used in this way.
          with whom I am linked financially may be used by the Society and other
          companies if credit decisions are made about me, or other members of my                   23   Limited Company Applications - I understand that it is normal society
          household. Any of this information may also be used for debt tracing and the                   policy to take directors guarantees in support of loans or mortgage.
          prevention of money laundering as well as the management of my account.
                                                                                                         Only tick the following boxes if you do not wish to be contacted by:
     11   An ‘association’ between joint applicants and/or any individual identified as my
          financial partner, will be created at credit reference agencies which will link our            Applicant 1                                 Applicant 2
          financial records. I and anyone else with whom I have a financial link understand               Post                                        Post
          that each other’s information will be taken into account in all future applications by
          either or both of us. This linking will continue until one of us successfully files a           Telephone                                   Telephone
          ‘disassociation’ at the credit reference agencies.                                              Email                                       Email
     12   Where I borrow or may borrow from you, you may give details of my account and
          how you manage it to credit reference agencies. If I borrow and do not repay in full
          on time, you may tell credit reference agencies who will record the outstanding

          Signature(s)                              Applicant 1                                                     Applicant 2/Guarantor *

          You must also sign
          the additional notes                      Date                                                            Date
          section on the reverse
          (if applicable)

          * By giving the guarantee you might be liable instead of or as well as the applicant(s).
          The guarantee will be limited and you should take independent legal advice before you give the guarantee.
11                                           THINK CAREFULLY BEFORE SECURING OTHER DEBTS AGAINST YOUR HOME.
Section 12 - DOCUMENTATION REQUIRED -                                            (if a Buy To Let Mortgage, please refer to product guide)

The following documents/information must be provided. Please enclose these with your completed application together with any other supporting evidence
you may feel relevant. Please tick the appropriate boxes if enclosed.

1.            Details of trading activities/business plan.
2.            Two years audited accounts of existing business.
3.            Two years audited accounts of the business being purchased (if appropriate).
4.            Administration fee.                Amount: £
5.            Curriculum Vitae of each applicant/partner/director.
6.            Existing or proposed tenancy agreements (if applicable).
7.            Personal asset and liability statements for each applicant/partner/director.
8.            Budgets and cashflow forecasts.
9.            3 months' personal statements.
10.           Copy of mortgage statement.
11.           Where renovations/improvements are to be carried out to the property copies of estimates or invoices relating to these.
12.           If not currently trading, please enclose details of current annual income, employment and your intention regarding this employment.
13.           Prospectus if available.
14.           Management Accounts.
15.           Six months business bank statements.

If the applicant is a body corporate:
16.           Memorandum and Articles of Association.

17.           Certificate of Incorporation.
18.           Details of the company and parent/subsidiary relationships (if any) including copies of last two years audited accounts.

N.B. Administration Fee if applicable must be included with the application.
A Valuation Fee will be advised and collected in due course.

    Use this space to give any additional information requested in any of the questions and any information which you feel will help the Society in assessing
    your application:

     Signature(s)                        Applicant 1                                                Applicant 2/Guarantor *

                                         Date                                                       Date

                  Monmouthshire Building Society
               Head Office: Monmouthshire House, John Frost Square,
                          Newport NP20 1PX, South Wales.
                       T: 01633 844 444 F: 01633 844 445
Monmouthshire Building Society is authorised and regulated by the Financial Services Authority   CLAPP001(07/06-1)

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