Every question must have a written answer. If a negative reply is intended put 'no' or 'none' where applicable.

APPLICANT'S NAME

TELEPHONE

ADDRESS

E-MAIL ADDRESS

1. (a)   Are you a Householder? YES NO   

(b)     How long have you lived at your present residence? If less than twelve months please give your previous address 
(c)    Is the furniture your own? YES NO   
If so, state (i) its  estimated value  (ii) whether it is free from all  liability 

2.    Please state (a) Age      (b) Nationality
   (c) whether single or married      (d) Number of dependants

3. Have you any property or are you entitled in reversion to any? YES NO
    If so, please state approximate value and the amount of any charges
    or mortgages in connection therewith 

4.  (a)     If you have any private liabilities or debts give particulars...
   (b)    Are you Security or Surety for any person?  YES NO

5.   Were you ever bankrupt or insolvent or have you ever arranged with your creditors? YES NO
If so, state when and if now discharged 

6.     Have any Court Judgements or Bills of Sale been registered against you? YES NO
If so, particulars must be given 

7.    Is your life assured? YES NO If so, state name of Company, amount of Policy and whether any   charge or assignment has been lodged against the Policy

8.   Do you represent other Firms? YES NO   If so, please give their Names and Addresses, and state if the Company may refer to them  

9   Have you made any previous application for Guarantees?  YES NO 
    If so, give the names of Companies, dates of applications, amounts and results 

11   Position or appointment for which this Guarantee is required and amount of Guarantee
Position Amount