Funding Consultation Questionnaire

Ms I Am HER - Credit Client Questionnaire
Contact Information
Name:

First NameLast Name
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com

Credit Profile
Current estimated credit score:
Placeholder (optional): e.g., 640, 700, 750
Credit utilization percentage:
Late payments (how many and how recent?):
Derogatory marks (list if any):

Credit Accounts
Number of open credit cards:
Number of installment loans:
Average age of credit accounts:
Number of recent hard inquiries:

Funding Readiness
Seeking personal or business funding?
Funding goal amount:
Existing LLC or business entity?
Business name:
Business in good standing?
Business bank statements for 3-6 months?

Goals and Expectations
Main credit/funding goal in the next 6-12 months:
Biggest challenge with your credit right now:
How soon are you ready to start improving your credit profile?

Acknowledgment
By submitting this form, I certify that the information provided is accurate to the
best of my knowledge.
Signature
Date

MonthDayYear
Date
Should be Empty: