Please Note: In order to qualify for the CreditTRAX Debt Settlement program you must have at least $8000.00 in unsecured debts to be settled.

*All Fields Are Required
First Name:
Last Name:
Phone:
Email Address:
Address:
City:
State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:
Date for Specialist to Call:		Select One Tue Sep 07Wed Sep 08Thu Sep 09Fri Sep 10Mon Sep 13
Specific Hour to Call:		Select One var date_to_call MenuList(date_to_call)
FDI ID#:
FDI Trainer's ID#:		(if applicable)
Total Amount of Unsecured Debt Owed:
Are You Behind In Payments?:		Select One Yes No
Have Any Creditors Issued Judgements Against You?:		Select One Yes No
Have You Filed Bankruptcy?:		Select One Yes No
If Yes, When?:
In the last 6 months, have you:
Made Any Major Credit Card Purchases?:		Select One Yes No
Made Any Balance Transfers?:		Select One Yes No
Made Any Cash Advances?:		Select One Yes No
Comments: