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CREDIT SERVICES Intake Form
Personal Information
First name
Last name
Email
*
Phone number
Date of birth
Street address
City
State/Region
Postal code
Previous address (if less than 2 years at current)
Credit Score and History
What is your credit score?
Please Select
Below 500
500-580
580-650
650-700
700+
What is your main credit concern? (Check all that apply)
Low credit score
Negative items (late payments, collections, charge-offs, etc)
Identity theft or fraud accounts
High credit utilization (maxed-out cards)
Too many hard inquiries
No credit history (need to build credit)
Public records (bankruptcies, liens, judgments)
Difficulty getting approved for loans, credit cards, or housing
Other
Would you like assistance with dispute letters to challenge inaccuracies?
Please Select
Yes
No
Do you have any existing loans or debts? Yes or no?
If Yes, Please estimate your total debt
Goals
Ex: "Start business," "Fix credit to buy house," "Need emergency funding"
Employment status
Employed / Self-Employed / Unemployed / Other
Desired Amount
Annual income
Government Assistance?
Option 1
Option 2
3
Documents List:
Make sure to locate all of these documents now so you can be ready when our representative contacts you!
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