Free Consultation Intake Form
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Primary E-mail (we will use this to create dispute accounts)
*
example@example.com
Secondary E-mail (if primary is not a gmail, add a gmail here. We will share google documents with you)
example@example.com
What is your current credit score?
*
Please Select
500 or below
500-600
600-700
700+
Enter Your Date of Birth
*
/
Month
/
Day
Year
Date
Consultation Interest
*
Please Select
Credit Repair
Business/Personal Funding
Credit Repair & Funding
You will be asked to provide sensitive information such as your social security number, driver's license, bank statement or any other document that may be needed to remove negative items from your credit report. We will not be able to move forward with you as a client if this is something you are uncomfortable doing. Do you understand and agree to share this information as part of the process? ***We will never ask you access to financial accounts
*
Yes
We need to identify you. Please upload a picture of your Driver's license
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
We need to identify you. Please upload a picture of your proof of address (No older than 1 month)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
We need to identify you. Please upload a picture of your original social security card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you open to changing your address on your ID if it helps your score?
*
YES
NO
Have you tried repairing your credit before by yourself or received help?
*
NEVER
BY MYSELF
HIRED A COMPANY
HAD A FRIEND TRY
What do you hope to achieve once your credit score is where you want it to be?
How much are you willing to invest to get control of your credit once again?
*
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DFY Section
Any information you provide here will speed up onboarding and setting up your success plan. We will be using these platforms to dispute items. We'd like to avoid having to text or call you about these so we can start working on your case immediately.
Provide your Experian.com login ID and Password.
Provide your Transunion.com login ID and Password.
Provide your Equifax.com login ID and Password.
Provide your credit karma login ID and Password
By clicking submit and signing this form, you agree to be contacted via SMS, Phone call or E-mail about your upcoming consultation, current and future services. All Primerich Literacy LLC attempts to contact you will always be relevant to your case. You will never be spammed. You may opt out of SMS any time by texting "Stop" to any of our contact forms including E-mail and Business phone number with your name and contact information. You also agree to share the aforementioned all pertinent information that will allow Primerich Literacy LLC to successfully restore your credit and secure you funding. You acknowledge that you understand that your information is completely safe and will solely be used for credit and funding purposes.
*
SUBMIT
SUBMIT
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