Section 1: Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section 2: Identity Verification
Upload a copy of your Driver’s License or State ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Proof of Address (Utility bill, bank statement, etc.)
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Choose a file
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Section 3: Credit Overview
What is your current credit score (if known)?
Have you checked your credit report recently?
Yes
No
Which credit bureaus have you reviewed?
Experian
Equifax
TransUnion
Not sure
Section 4: Credit Goals
What is your main goal for credit repair?
Buy a home
Buy a car
Business funding
Personal improvement
Other
What is your target credit score? (if known)
Section 5: Negative Items
What negative items are on your credit? (Check all that apply)
Late payments
Collections
Charge-offs
Repossessions
Bankruptcy
Hard inquiries
Other
Please list any specific accounts you want removed or reviewed:
Section 6: Credit History
Have you worked with a credit repair company before?
Yes
No
If yes, what was your experience?
Section 7: Open Accounts
Do you currently have active credit cards?
Yes
No
Total number of open accounts (if known):
Are your current accounts in good standing?
Yes
No
Section 8: Payment & Commitment
Are you committed to improving your credit?
Yes
No
Are you able to make on-time payments moving forward?
Yes
No
Section 9: Authorization
I authorize review of my credit report for the purpose of credit repair.
*
Yes
No
I confirm all information provided is accurate.
*
Yes
No
Preferred Contact Method: Call / Text / Email
Section 10: Document Upload
Upload your credit report (if available)
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Upload any supporting documents (letters, statements, etc.)
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Credit Repair Services
$399.00
$
399.00
Debit or Credit Card
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