Short Application

Contact Info
First Name*
Last Name*
Total Number of People in family*
Number of Dependant Children*
City*
Province*
Home Telephone*
Cell Phone
Preferred Phone
Best Time to Call
Best Call Day/Time
E-Mail*
Confirm E-Mail
How did you find out about us?
Add me to your mailing list?	Yes No

Current Situation

How much UNSECURED Debt do you have? *

What is your net monthly household income? * $

Types Of Debt - please check all that apply

Credit Card
Finance Company Loans
Line Of Credit
Bank Overdraft
Personal Loans

Overdue Rent or Utilities
Student Loans
Government Debt
Secured
Other

Are any of your debts joint or co-signed?	Yes No N/A
Have you been turned down for a loan?	Yes No N/A
Are you interested in consolidating debts into one monthly payment?	Yes No N/A
Are you receiving collection calls?	Yes No N/A
Are your payments up-to-date?	Yes No N/A
Are you receiving income?	Yes No N/A
Do you have an account in a bank to whom you do not owe any money?	Yes No N/A

Comments: What would you like us to help you with?

FAQ/Terms*: I have reviewed the frequently asked questions page and agree to the terms and conditions below.

This application does not obligate you in any way to purchase any products or services.
The privacy of the personal information you have provided will be carefully protected.
Your contact information will not be sold, rented or distributed in any form.
It is for the sole express purpose of allowing us to send you information about our products and services.

AA Credit Counsellors

Short Application

Contact Info

Current Situation