Client Intake & Credit Profile Questionnaire

Credit Education Interest Form
Client Identification
Full Name*

First NameLast Name
DOB*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
PhoneEmailText
Identification

Used solely for identification purposes
Government Issued Photo ID*

Cancelof
Proof of Address (Utility bill / Lease)*

Cancelof
Social Security Card*

Cancelof
Credit Profile Overview
Current Credit Score Range*
Late PaymentsCollectionsCharge offsRepossessionsForeclosureBankruptcyJudgements
Credit Goals
Home purchaseAuto loan approvalCredit card approvalsBusiness fundingDebt consolidationScore improvement
30-60 days3 months6 months12 months+
Financial Snapshot
EmployedSelf-EmployedUnemployedStudentRetired
Under $2,000$2,000–$4,000$4,000–$6,000$6,000+
Monthly Debt Obligations*
Previous Dispute Activity
YesNo
YesNo
YesNo
YesNo
Compliance & Disclosures
Serenity Consulting Group provides credit consulting and educational services. We do not guarantee specific results. Outcomes depend on the accuracy of information reported and responses from credit bureaus and furnishers.
I acknowledge that results cannot be guaranteed.
Authorization
I certify that the information provided in this intake form is accurate and complete to the best of my knowledge. I authorize Serenity Consulting Group to review my credit profile and provide consulting services.
Signature*

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Credit Education Interest Form

Client Identification

Identification

Credit Profile Overview

Credit Goals

Financial Snapshot

Previous Dispute Activity

Compliance & Disclosures

Authorization