Credit Repair & Financial Education Intake Form
Mobile-friendly intake form for nonprofit credit education and related appointment preferences. Georgia residents will see a Georgia-specific education-only notice; all other states default to education only. Please review the required disclosures before signing. This form does not collect SSN, DOB, account numbers, sensitive uploads, or payment details.
Contact Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Please Select
Phone
Email
Text
Eligibility / Residence
State of Legal Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
District of Columbia
County of Residence
*
I confirm I am 18 years of age or older
*
Option 1
Option 2
Option 3
Georgia education-only notice
Georgia acknowledgment
*
Option 1
Option 2
Option 3
Other states availability notice
Request eligibility review for additional services
Option 1
Option 2
Option 3
Educational Interests and Appointment Preference
Educational topics of interest
*
Budgeting basics
Understanding reports and scores
Debt management
Identity protection
Dispute process overview
Credit-building strategies
Other
Appointment preference
*
Acknowledgment and consent
*
I understand this service provides education only and not legal advice
I understand there is no guarantee of any result
I understand accurate negative information cannot be removed
I understand this provider is not acting as an agency or filing disputes on my behalf
I understand there is no obligation to buy services
I consent to be contacted about intake only
Marketing consent
I agree to receive marketing messages and promotional updates
Privacy and resources
Type your full name to sign
*
Signature date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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