Credit Form First Name:* Last Name:* Age: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email:* Tell Us About Your Complaint Subject of Your Complaint: Name of the company you are complaining about: (If unknown, write "unknown") Address: City: State: Zip: Company Website: Company Email: Company Phone: Extension: How did the company initially contact you? How much did the company ask you to pay? How much did you actually pay the company? How did you pay the company? Please select one: Personal Check Business Check Visa Mastercard Discover American Express Other If other payment method, please indicate it here: Did you file a dispute with the Credit Bureau? Please select one: Yes No Did you file a dispute with the Credit Bureau more than 45 days ago? Please select one: Yes No Representative or Salesperson First name: Last Name: Date Company Contacted You: Explain your Problem Share This Page:
