LOANS MADE SIMPLE

Pitcher & Le Quesne Funeral Loan Application Form

Personal details:

Please ensure all mandatory fields marked with an asterisk (*) are populated.

Title*:

First Name*:

Surname*:

Marital Status*:

Years on Island*:

Contact Details:

Mobile Number*:

Home Number:

Work Number

Email:

Home

Residential Status:

Current Address

Address Line 1*:

Address Line 2:

Parish:

Postcode*:

Years at Address*:

Months at Address*:

Previous Address

Address Line 1:

Address Line 2:

Parish:

Postcode:

Years at Previous Address:

Months at Previous Address:

Work

Current Employer

Employer*:

Occupation*:

Address Line 1*:

Address Line 2:

Postcode*:

Years at Current Employer*:

Months at Current Employer*:

Previous Employer

Employer:

Occupation:

Employer Address Line 1:

Employer Address Line 2:

Employer Postcode:

Years at Previous Employer:

Months at Previous Employer:

Your Loan Enquiry

Amount*:

Preferred Term (Months)*:

Reason for loan:

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The loan amount will be paid direct to Pitcher & Le Quesne once approved

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'Whatever your financial needs may be, everyone can benefit from TLC'