Debt Consolidation Application Form

Please fill this confidential form in completely. Must be 18 years are older to apply. Upon receipt, one of our credit consultants will review the information and prepare a quote. Within 48 hours the consultant will be in touch with you via phone or email to discuss your savings. If you have questions about this form you can call our customer service department at 704-528-8260 Eastern Time. Thank You!

* denotes required fields

First Name: *
Last Name: *
Co-Applicant
First Name:
Last Name:
Address: *
City: *
State: *
Zip Code: *
Home Phone: *
Work Phone:
Email Address: *
Best time to call (and where) *
Total Unsecured debt: * 0-$5000
5000 - $10,000
10,000 - $15,000
over $15,000
Creditor Name 1           Debt Type:
Balance Due           Interest Rate
Monthly payment           Payment Status:
Creditor Name 2           Debt Type:
Balance Due           Interest Rate
Monthly payment           Payment Status:
Creditor Name 3           Debt Type:
Balance Due           Interest Rate
Monthly payment           Payment Status:
Creditor Name 4           Debt Type:
Balance Due           Interest Rate
Monthly payment           Payment Status:
Enter any Comments
you may have
(1000 characters max.)