Form
Credit Client Intake
Please fill out this form accurately. Fields with * are required and must be filled.
How did you hear about us?*
Marketing (Flyer, Business Card, Etc.)
Returning Client
Facebook
Instagram
Google
Referral
Other
Credit Repair Onboarding
Name*
First Name
Last Name
Date of Birth*
-
Month
-
Day
Year
Date
Social Security #
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / 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 are a concern?*
Yes
No
REQUIRED DOCUMENTS
Proof of Residence (Lease, Utility Bill, W2)
*
Browse Files
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of
Driver's License/ID Card
*
Browse Files
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of
Social Security Card
*
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of
Misc. Forms
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of
Take a selfie with your ID next to your face
*
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of
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: