US Consumer Credit Restoration Association
Membership Enrollment Form
Fill out the Form below to begin the membership enrollment process
Client Information
First Name
*
Last Name
*
Middle Initial
Email Address
*
Date of Birth
*
SSN
*
Cell Phone
*
Home Phone
*
Work Phone
Home Address
*
City
*
State
*
Zip Code
*
Membership Plan Selection
*
-- Please select --
Individual Gold (initial fee $207 then $107 mo)
Individual Platinum (initial fee $207 then $137mo)
Individual Platinum + (initial fee $207 then $177mo)
Family Gold (initial fee $377 then $187mo)
Family Platinum (initial fee $377 then $257mo)
Family Platinum + (initial fee $377 then $317mo)
2nd Family Member
(if choosing a family plan)
First Name
Last Name
Middle Initial
Date of Birth
SSN
Email Address
Cell Phone
Home Phone
Billing Information
Billing Address
*
City
*
State
*
Zip Code
*
Billing Option
*
-- Please select --
Check Draft or Money Order
Credit Card Details
Name on Card
Card Number
CCV Number
Card Expiration
01
02
03
04
05
06
07
08
09
10
11
12
2012
2013
2014
2015
2016
2017
2018
2019
2020
Check Draft Details
Bank Account Holders Name
Name of Bank
9 Digit Routing #
Account #
Date to Draft Initial Installment
Date to Draft Check
-- Please select --
1st
5th
15th
20th
25th
Terms and Conditions
I have read and agree with the Terms and Conditions
I have read and agree with the Privacy Policy