Funding Intake Form

PATIENCE PAYS LLC

307 West Tremont Ave.

Suite 200 Charlotte, NC 28203

credit@patiencepays.net

(800) 788 9089
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
What best describes you?*
How much funding are you seeking?*
What is your personal credit score?*
How many accounts do you have open on your credit report?*
Collections/ChargeoffsRepossessionLate PaymentsBankruptcyNo, my credit is clean!
$5k or less$5k - $15k$15k - $30k$30k or moreI don't have any credit cards
How did you hear about us?*
If you were referred to us by family or a friend please type their name below.
Should be Empty: