REQUEST DETAILS
How would you
like
to be contacted?
Call me
E-mail me
Send me info packet by mail
Would you like to set up an online demo?
Yes
Not sure
Not at this time
Would you like information about our:
Credit Counseling Software
Debt Settlment Software
Both
Do you have any questions you would like
us to
address or comments?
CONTACT
INFORMATION
Contact Name:
Agency/Company Name:
Title:
Phone:
ext
Fax:
E-mail:
Web Site Address:
Address:
City:
State/Province:
Zip/Postal:
Do you have the authority
to purchase
this software
for you agency?
Yes
No
If no, provide the name
of the
person who does:
Phone Number:
ext
AGENCY
INFORMATION
How would
you classify
your agency?
(Select ALL that apply)
Credit Counseling
Debt Settlement
Debt Consolidation
Debt Education Center
Other Financial Institution
How
long has your company
been in business?
< 1 year
1 to 4 years
5 to 10 years
> 10 years
Approximately
how many active clients does your agency currently
service?
1-500
500-1,000
1,000-5,000
5,000-10,000
10,000-50,000
50,000+
What is
your current
growth expectation?
# of Users:
# of Computers:
# of Servers:
SYSTEM INFORMATION
What software are
you
currently
using
to
run your operation?
How satisfied
are you with
your current software?
very unsatisfied
unsatisfied
satisfied
very satisfied
What
major functionality would
you
like to have in place
that
you
currently
do not have?
Will your existing database
require conversion?
Yes
No
Will you
need to purchase
a Creditor Database ?
Yes
No
What is your
expected time
frame
for the implementation
of a
new
software application?
< 1 month
1 to 3 months
4 to 12 months
> 1 year
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Security Code:
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