Application
Fields marked with a (*) are required.
First Name*
Last Name*
Email Address*
Confirm Email Address*
Home Phone*
Work Phone
State / Province*
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- - - - - - - - - - - - - - - -
Alberta
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Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
What is your primary goal?*
none chosen
Stop collection calls
Pay off debts sooner
Avoid Bankruptcy
Relief from fees and interest
Purchase a home
Purchase a vehicle
Reduce payment amounts
Have only one payment
Avoid job loss
What is your situation?*
Receiving collection calls & letters
Legal action
Unemployed
Reduction in income
Medical bills
Divorce/seperation
Overspending
Unmanageable interest rates
Denied credit
Poor money management
Unfavorable credit rating
Moving expenses
Family emergency
How should we contact you?
No Preference
Contact Me by Phone
Contact Me Through Email
Best time to reach you
Morning at home
Morning at work
Afternoon at home
Afternoon at work
Evening at home
Evening at work
Estimated Total Debt
<- $5,000
$5,000-$10,000
$10,000-$15,000
$15,000-$20,000
$20,000-$25,000
$25,000-$30,000
$30,000-$35,000
$35,000-$40,000
$40,000 ->
How did you hear about us?
internet search
newspaper
radio
television
yellow pages
billboard
drive-by
friend/relative
former client
bank
attorney
creditor
Enter the two words below
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credit advisors
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foundation
1818 South 72nd Street
Omaha, Ne 68124
800-942-9027