Credit Repair Order Form

This form is for gathering information to enable the credit repair process to commence.

If you wish to appoint Credit Medic to carry out Credit Repair on your behalf you will first need to complete the Order and Authorisation form below.

Once completed this can be submitted to Credit Medic simply by pressing the submit button.

In submitting yiour details you are acknowledging that you have read and accept the Terms & Conditions contained within this web site and you are authorising Credit Medic to commence Stages 1, 2 & 3 referred to in the explanation given on the Credit Repair main page.

This commits you to a fee of £117.50 .

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Please Complete the Order and Authorisation Form below to place your Order
I hereby authorise Credit Medic Limited to obtain copies of my credit files held with Experian and Equifax and to provide me with a detailed analysis of information held by the credit reference agencies and in particular bring to my attention anything which may be considered adverse in nature.
Customer Name in Full:*
Customer Address:*
City:
Post Code:*
   
Contact Phone - Land Line:
Contact Phone - Mobile:
Contact Fax:
Contact E-Mail:*

Please supply any previous addresses in the past 6 years below:
Cardholder Details & Address
Title
Surname
Forenames
Address
Email Address
Payment Option
Card Number
Card Valid Date (MM/YY)
Card Expiry Date
Issue Number
Security Number

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