Debt Consolidation Services: Debt Relief, Debt Management Program, Debt Reduction, Debt Counseling, Credit Counseling, Debt Management, Consumer Credit Counseling, Debt Help, Debt Management Company

1-800-BETS-OFF

On-Line Application and Request for Appointment: Page 1 of 3

*Please indicate one main reason* for requesting an appointment:**
Over-obligation (Excessive Spending) Unemployment--Loss of Income Reduced Income Unexpected Medical Costs Accident/Disability	Gambling Divorce/Separation Filing For Bankruptcy Other (Please Specify)

Select your state:

Do you have an appointment scheduled?
Yes No
Would you like to be called to schedule an appointment?
Yes No

Important Instructions
It is vital that as much of this form be completed before your first appointment.
Items with a red asterisk () are required.

First Name:
Middle Initial:
Last Name:
Spouse's Name:
Present Address:
City:
Zip:
# of people in home:
Telephone number to call:
Best Time to Call:
Daytime Telephone:
Evening Telephone:
Email:

Occupation
Timing of Paydays:		Take Home pay $
Other Income Source:		Amount $

Spouse's Occupation:
Timing of Paydays:		Take Home pay $
Other Income Source:		Amount $

Have you ever filed Bankruptcy? Yes No Year

Amount of Last Year's Tax Refund: $

National Association of Certified Credit Counselors

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