Credit Repair Intake Form
Client Information
First Name
*
Last Name
*
Credit Monitoring System
*
Name of credit monitoring system
Security Question
If applicable for CMS - answer to question
Username
*
Password
*
Previous or current credit repair activity
Has the client previously worked with another credit repair company or is currently working with one?
*
No
Yes
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Was the client residing at the same address during the time the account(s) were tagged as a charge-off
*
No
Yes
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The date when credit was last worked on or any prior disputes were submitted.
Referral
Did anyone refer you to Inquiry Removers
Who Helped You
*
Apple
Loren
Toni
No One
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Which of our reps helped you
Submit