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First Name
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Email Address
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Phone Number
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age
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Age Range
18-25
26-40
41-65
66-100
employment
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Current Employment Status
Employed Full-Time
Employed Part-Time
Self-Employed
Unemployed
Retired
Student
income
*
Total Monthly Income
Below $1,000
$1,000-$2,999
3,000-4,999
5,000-6,999
7,000 and above
debt
*
Total Amount of Debt
Less than $5,000
5,000-10,000
$10,000-20,000
$20,000-50,000
More than $50,000
Type of Debt (check all that apply):
*
Credit Card Debt
Medical Bills
Personal Loans
Student Loans
Other__
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What is your primary goal with debt consolidation?
Lower monthly payments
Reduce interest rates
Simplify payment
Become debt free?
Other__
Are you Currently Behind on any Payments?
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Yes
No
how did you hear about us
How did you hear about Honest Choice Solutions?
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3439 VESTAL PKWY E STE 2 #219 VESTAL NY 13850
9:00 AM - 11:00 PM
in
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(607) 321-7508
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