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First Name
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Last Name
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Email
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Phone Number
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Date of birth
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How did you hear about us?
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Address
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City
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State- example (TX)
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please type state in two letter Abbreviations Example Florida (FL) all capitals
Zip Code
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Employer name
gross monthly income
Occupation (Self employed and government assistance can also apply)
Do you have collections?
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Are you in a bankruptcy
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Are you in a consumer proposal?
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what are you looking for?
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loan
Credit card
vehicle loan
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What bank do you deal with?
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How long have you been with your bank?
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Will you be using this bank account for your loan/credit card repayment and subscription to Amplified Credit?
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please sign your name below with your Signature
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