Credit Repair Consultation Form
The PowerHouse Group
Personal Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
.
Month
.
Day
Year
Date
Last 4 of Social
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Credit Information
Are there any blemishes on your credit report?
*
Late Payments
Collections
Lien
Bankruptcy
Repossession
Judgement
Other
Are you having trouble qualifying for any of the following things?
Auto Loans
Jobs
Mortgages
Loans
Credit Cards
Apartment/Condo
Other
Credit Score
*
Ex: 800-850 as excellent
Have you ever had credit repair done before?
*
Yes
No
Other
Why do you need credit repair?
*
Which credit monitoring site do you use?
*
IdentityIQ
SmartCredit
MyFreeScore Now
MyScoreIQ
PrivacyGuard
Credit Hero
None, if none we ask that you create an account with either of the websites above prior to your consulation meeting.
Are you able to pay a one time repair fee of $350-$700?
*
Yes
No
Any questions?
Did someone refer you? If so, please list their name here.
Submit
Should be Empty: