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1 Your Personal Details

• Title: Choose Mr. Ms. Mrs. Miss Other
• First Name:
• Last Name:
• Email:
• Please Confirm Email:
• Home Phone:
• Mobile Phone:
• Work Phone:
• Date of Birth:

  (dd/mm/yyyy)

2 Your address details

• Postcode:
•  
  
• Addresses
• House Name/No.
• Address:
• Town/City:
• County: Choose Antrim Ards Armagh Bedfordshire Ballymena Ballymoney Banbridge Belfast Berkshire Borders Region Bristol Buckinghamshire Cambridgeshire Carrickfergus Castlereagh Central Region Cheshire Channel Is Clwyd Coleraine Cookstown Cornwall Craigavon Cumbria Derbyshire Derry Devon Dorset Down Dumfries & Galloway Region Dungannon Durham Dyfed East Riding of Yorkshire East Sussex Essex Fermanagh Fife Region Gloucestershire Grampian Region Greater London Greater Manchester Gwent Gwynedd Hampshire Herefordshire Hertfordshire Highland Region Isle of Man Isles of Scilly Isle of Wight Kent Lancashire Larne Leicestershire Limavady Lincolnshire Londonderry Lothian Region Lisburn Magherafelt Merseyside Mid Glamorgan Middlesex Moyle Newry and Mourne Newtownabbey Norfolk North Down North Yorkshire Northamptonshire Northumberland Nottinghamshire Omagh Orkney Is Oxfordshire Powys Rutland Shetland Is Shropshire Somerset South Glamorgan South Yorkshire Staffordshire Strabane Strathclyde Region Suffolk Surrey Tayside Region Tyne & Wear Tyrone Warwickshire West Glamorgan West Midlands West Sussex West Yorkshire Western Isles Wiltshire Worcestershire

3 Your loan information

• Loan Amount(£):
• Employer Name:
• Primary source of income? Choose Pension Disability Benefits Unemployed Full-Time Employment Part-Time Employment Self Employment Temporary Employment
• Net Monthly Pay(£):
• Paid by Direct Deposit? Choose Yes No
• Pay Frequency: Choose Last Working Day of Month Four-weekly Specific Day of Month Last Monday of Month Last Tuesday of Month Last Wednesday of Month Last Thursday of Month Last Friday of Month
• Time at Employer: Choose < 2 Years 2-4 Years 4-8 Years Over 8 Years
• Do you have a Debit Card? Choose Switch/Maestro Solo Visa Delta Visa Electron No Debit Card
• Next Pay Date:

  (dd/mm/yyyy)

Important – Please Read

I have read and am happy with MEM Consumer Finance Ltd’s loan conditions

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• You must confirm this before continuing with your loan application

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