Client Intake and Authorization Form

Client Intake and Authorization Form

Please complete this form to begin the credit repair process. Upload required documents and provide your authorization.
Client Profile Information

Please provide your basic details below.
Full Name*

First NameLast Name
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 / ProvincePostal / Zip Code
Upload a photo or scan of your government-issued identification document (do not include sensitive numbers).*

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Upload a recent proof of address (utility bill, bank statement, or similar).*

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Please include your Experian's Users Name here.
Input your Experian's Password Here.
Referred BY
Client Authorization and Consent

Please review the authorization statement below and sign electronically to proceed.
Electronic Signature*

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