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123 Credit Restoration Intake Sheet

Full Name _________________________________________________________

DOB______________________

SSN_______________________

Address_____________________________

            ______________________________

            ______________________________

Apt #  _______________

Previous Address if at current address less than two years

_____________________________________

_____________________________________

Phone________________________

Email________________________________

Drivers License ID No.__________________________

County and State born in_____________________________

Current employer and previous employers possibly on your reports
________________________________________________________________________________________________________________________________________________________________________________________________________________

Mortgages (for all please list the creditor, rough monthly payment and year opened)
________________________________________________________________________________________________________

Auto Loans (for all please list the creditor, rough monthly payment and year opened) ________________________________________________________________________________________________________

Signature_____________________________     Date_________________________

PAYMENT INFORMATION:

Name on Credit Card: ________________________________________

Card Number:  ______________________________________________

Expiration Date:  ­­­­­­____________________________________________

3 Digit Security Code on the back:  _____________________________

Billing Zip Code:  ____________________________________________

Authorized initial payment amount:  ____________________________

FAX TO: 315-689-4022
EMAIL TO: 123CreditRestoration@gmail.com
MAIL TO:  PO BOX 8545 Utica NY 1305
OR Call to set up an in person intake at our office at 287 Genesee St. Utica, NY 13501



***All of our services have a complete money back guarantee.