Credit Client Intake
Please fill out the form accurately. Fields with * are required and must be filled.
How did you hear about us?
*
Please Select
Marketing (Flyer, Business Card, etc.)
Returning Client
Facebook
Instagram
Google
Referral
Other
Who referred you?
*
Credit Repair Onboarding
First Name
*
Middle Name
*
Last Name
*
Suffix (if applicable)
Date of Birth
*
-
Month
-
Day
Year
Social Security #
*
Email
*
example@example.com
Phone Number
*
-
Area code
Phone number
Current Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Did you set up your Identify IQ?
*
Yes
No
Add Credentials Here
*
Last 4 of SSN
*
Do you have any Bankruptcy, Child support, Foreclosure or Repossessions on your credit report that is a concern?
*
Yes
No
REQUIRED DOCUMENTS
Proof Of Residence (Lease, Utility Bill, W2)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Driver's License / ID card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Social Security Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Misc. Forms
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Selfie with your ID next to your face
*
Signature
*
*
Please verify that you are human
*
SUBMIT
Should be Empty: