CREDIT REPAIR INTAKE FORM
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Credit Situation Questions
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
What are the biggest issues on your credit report? (Check all that apply)
Late Payments
Collections
Repossessions
Student loans
Child Support
Charge Offs
Other
Bankruptcy
Which credit bureaus are reporting these issues? (Check all that apply)
Experian
Transunion
Equifax
Im not sure
Goals & Motivation
What are your credit goals? (Check all that apply)
Buy a house
Get a car
Personal funding
Business funding
Just want a better score
Other
How soon are you looking to improve your credit?
ASAP
In 30 days
In 2-3 months
Budget & Readiness
Are your ready to invest in fixing your credit today if its affordable?
Yes
No
I need more info
Our credit repair service is $500. Are you able to invest in this today?
Yes
No
I'd like an affordable payment plan
Follow up within 1-2 weeks
Extras (Optional)
Would you like a free credit analysis before we get started?
Yes
No
Submit
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