You must meet the following requirements to be eligible for this program:

Minimum Debt Of $35,000
Minimum Of 3 Creditors
Minimum Monthly Payment Of $1,000 Or More Per Month

Company Name:
Contact Name:
Title:
Company Address:
City:
State:	----Select a State----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:
Company Phone:
Company Fax:
E-Mail:
Type of Business:	----Select an Entity----- Sole Proprietorship Partnership LLC Corporation
Total Amount of Debt:	----Select an Amount---- $15,000-$30,000 $30,000-$75,000 $75,000-$150,000 $150,000-$500,000 More than $500,000
Can you afford to pay 2%- 3% of your debt per month? (Minimum $1,000 per month)	Yes No
Where did you hear about us?	----Select a Source---- Newspaper Magazine Television Radio Referral Internet Mail Other
Describe Your Debt:
How much total debt do you have with vendors, leases and credit cards over 90 days?
What is the total number of creditors that you owe?