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? *

Was the client residing at the same address during the time the account(s) were tagged as a charge-off *

The date when credit was last worked on or any prior disputes were submitted.

Broker Information

Broker

Broker name or company name