Credit Services Intake Form

Collect a new client's personal information, credit history, and required authorizations to begin a credit dispute or repair process.

Use this template

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Welcome to our credit services intake process.

Please complete the following information as accurately as possible.

All information provided will be treated as confidential.

Please read and acknowledge the following:

You understand that we do not retain copies of all the paperwork you send us. For confidentiality and security reasons, only a limited amount of information is kept in your physical file, and everything else is shredded. It is your responsibility to keep copies of any documents you may need to reference later.

I understand and agree

You understand that you should not send us original court documents or collection notices. Only send copies of documents that support your case (proof of payment, court dismissal records, etc.). We do not act as your legal representative, so it is your responsibility to seek outside legal counsel if you ever need protection of your rights.

I understand and agree

Client Acknowledgment

By signing below, you confirm the statements above.

Client Name

Nombre

Apellido

Signature

Sign here

Spouse or Co-Applicant Signature (if applicable)

Name

Nombre

Apellido

Signature

Sign here

Full Name

Nombre

Apellido

Current Address

Dirección

Ciudad

Estado / Provincia

Código postal

Previous Address (If less than 3 years)

Dirección

Ciudad

Estado / Provincia

Código postal

Home Phone

Mobile Phone

Work Phone

Fax Number

Date of Birth

Employed By

Nombre

Apellido

Referred By

Nombre

Apellido

Reason for Credit Repair

Have you and your spouse ever used a credit repair company to dispute any accounts before?

Yes No

Name of Company

When?

What accounts were disputed?

Are you planning on making any large purchases on your credit cards even though you will pay it off in a short time?

Yes No

This is an important question because your utilization ratio can increase and lower your score during our process of improving your credit. Please write your initials confirming you understand this.

Date

Signature

Sign here

Co-Applicant Signature

Date

Signature

Sign here

Credit Services Intake Form

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