Interest Rate Confirmation Form

Full Name

Date of Birth

Phone

Full Name

Date of Birth

Phone

New Zealand Resident

YES

Common Email

Your Current Address

Please confirm that you have read the public available disclosure statement for Insurance & Mortgage Network and personal disclosure for Jai Bothra

YES

Please fix my loan/s for:

I confirm the interest rate is:

I have selected this loan structure because of the selected structure is affordable

I have selected this loan structure because of the selected structure suits my/our needs

I have selected this loan structure because of the term' s length

I declare that the information provided to the best of my knowledge are accurate

YES