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Bank Details for Commission Payments
If leaving a Network, please provide the following:
Address History (Please Provide 3 Years)
Current Address
Postcode
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Postcode search results
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House Name or Number
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Address Line 1
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City
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County
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Country
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Effective From
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Employment History (Please Provide 8 Years)
Current Employment
Employer Name
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Employer Role
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Notice Handed In?
Date Notice Handed In
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Notice Leave Period
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Postcode
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Lookup
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Postcode search results
Search results for:
Select
House Name or Number
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Address Line 1
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City
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County
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Country
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Effective From
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Reason For Leaving
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Can We Reference?
Yes
No
Contact Name For Reference
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Email For Reference
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Can We Character Reference?
Yes
No
Contact Name For Character Reference
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Email For Character Reference
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Directors
Full Name
Role
Directors Share
Shareholders Share
Links will be sent to each Additional Director where applicable for them to complete their own information
What will be the split of income between mortgage, general insurance, and life insurance?
How many cases have you completed in the previous 12 months and how many do you anticipate to complete on in the next 12 months? – relevant to PI (kindly provide a forecast/ estimate)
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Please provide full details of why the candidate is competent and capable to carry out the controlled function(s) applied for. For firms of your type, when asking for further information from you we will generally ask for a description and documentation setting out how the competency was assessed(demonstrating competence and suitability mapped to the specific role and its responsibilities).It may therefore help speed up your application if you provide these details along with this application
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Please provide full details of why the appointment complements the firm's business strategy, activity and the markets in which it operates (where applicable)
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Please provide full details of how the appointment was agreed, including details of any discussions at governing body level (where applicable)
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Employees
First Name
Last Name
Email
Disclosure
1a. Have you ever been convicted of any offence involving fraud, theft, false accounting, offences against the administration of public justice (such as perjury, perverting the course of justice and intimidation of witnesses or jurors), serious tax offences or other dishonesty or an offence relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, consumer credit or consumer protection, money laundering, market manipulations or insider dealing? (Spent convictions for relevant offences need not be disclosed in accordance with the Rehabilitation of Offenders Act 1974).*
Yes
No
More Information
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1b. Are you the subject of any current criminal proceedings?*
Yes
No
2. Have you any convictions for any offences other than those listed in 6 below which are not spent, (excluding traffic offences unless these resulted in a ban from driving or involved driving without insurance)?*
Yes
No
3a. Are you, or have you ever been, the subject of any civil proceedings, arbitration or litigation, including proceedings that may lead to a County Court Judgement (CCJ) or other judgement debts?*
Yes
No
3b. Are you aware of any intention to begin such proceedings against you in the future?*
Yes
No
4a. Are you, or have you ever been, the subject of any bankruptcy proceedings, or proceedings for the sequestration of your estate?*
Yes
No
4b. Have you ever entered into a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so?*
Yes
No
5. Do you have any outstanding financial obligations arising from regulated activities which you have conducted in the past?*
Yes
No
6. Have you ever been found guilty of conducting any unauthorised regulated activities or been investigated for possible conduct of unauthorised regulated activities?*
Yes
No
Have you ever:
7. Are you, or have you ever been, the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?*
Yes
No
8a. Been refused entry to, or been dismissed or requested to resign from, any profession, vocation, office or employment, or from any fiduciary office or position of trust, whether or not remunerated?*
Yes
No
8b. Been refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?*
Yes
No
8c. Been disqualified by a court from acting as a director of a company or from acting in a management capacity or conducting the affairs of any company, partnership or unincorporated association?*
Yes
No
In respect of activities regulated by the FCA or any other regulatory body, have you, or has any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever:
8d. Been the subject of a disqualification direction under section 59 of the Financial Services Act 1986 or a prohibition order, under section 56 of the Financial Services and Markets Act 2000, or received a warning notice to make such a direction order?*
Yes
No
9a. Been refused, had revoked, restricted or terminated, any licence, authorisation, registration, notification, membership or other permission granted by any such body?*
Yes
No
9b. Been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any such body?*
Yes
No
9c. Resigned whilst under investigation by, or been required to resign from, any such body?*
Yes
No
9d. Decided, after making an application for any licence, authorisation, registration, notification, membership or other permission granted by any such body, not to proceed with it?*
Yes
No
9e. Been the subject of any civil action which has resulted in a finding against you or it by a court?*
Yes
No
Has any company, partnership, or unincorporated association of which you are or have been a controller, director, senior manager, partner, or company secretary, at any time during your involvement or within one year of such an involvement :
10a. Been put into liquidation, wound up, ceased trading, had a receiver or administrator appointed or entered into any voluntary arrangement with it’s creditors?*
Yes
No
10b. Been adjudged by a court liable for any fraud, misfeasance, wrongful trading or other misconduct?*
Yes
No
10c. Been investigated or been involved in an investigation by an inspector appointed under companies or any other legislation, or required to produce documents to the Secretary of State, or any other authority, under such legislation?*
Yes
No
10d. Been convicted of any criminal offence, censured, disciplined or publicly criticised, by any inquiry, by the Takeover Panel or any governmental or statutory authority or any other regulatory body (other than as already indicated under ix b above)?*
Yes
No
10e. Had any complaints registered against you whether upheld or not?*
Yes
No
11. Have you ever been kicked off a lender or protection panel?*
Yes
No
If an answer is “YES” please provide details in the notes section
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