Phone: 954-484-5165		 
         Fax:      954-484-5695
         Email: mikem@optimumcredits.com     
	        
				Client Information Sheet

Last Name: ________________      First Name:______________      Middle:___
Date of Birth: _______________     SS#: ____________________
Current Mailing
Address: ______________________________________________________

City: ___________________ State: __________ Zip Code: _____________
Previous Address if less than two years: ___________________________
_________________________________________________________________
	Home Phone: ________________ Cell: ________________ Work: ___________
 E-Mail address: ________________________________________
Reason why the credit need to be repaired? _____________________
______________________________________________________________
How did you hear about us? _________________________________________
Amount Paid ______________     Balance ______________                 
How did you hear about us? _________________________________________
Signature_____________________________   Date ______________