Online Panel Form

*Existing Introducers to Halifax, do not need to fill in this form unless you are advising us of a change of details.

Intermediary Registration/Amendment - Please complete the following form to register as a new user to Halifax Intermediaries, request an additional payment route to a mortgage club/network or amend the details we hold about your company.

Which business area does this request relate to *

0 Mortgages General Insurance Mortgages & General Insurance

Type of request *

0 New Contact (New to Halifax) New/Additional Payment Route Amend Intermediary Details

Do you require an E-Service Disk

0 Yes No

Please indicate if you have registered to do business with the following brands

Bank of Scotland TMB

Section 1 - Intermediary Details

Select type of Intermediary *

0 Mortgage Broker Estate Agent Accountant Builder Solicitor

Name of Network/Mortgage Club/ Payment route(s) * †

If you are registered as an Appointed Representative please ensure that the required payment route has been authorised by your Principle)

Intermediary/Contact name *

Company Name *

Address Line 1 *

Address Line 2

Address Line 3

Post Town *

Post Code *

Telephone Number *

 

Fax Number

Mobile Number

Email Address *

Name of Business Development Manager (If Applicable)

† In certain cases we may need your bank details to complete our processes. If this is the case we will contact you via telephone or email.