Personal Credit Services Mail Order Form

Print out this form, fill it out and mail it along with proper payment to:

Personal Credit Services Inc.

321 Dante Court (Suite # A1)

Holbrook, NY 11741

Your Name_______________________________________________

Your 6 digit Client ID#_________________________________

Address_______________________________________________________

____________________________________________________________

City______________________________

State_____________________________

Zip______________________________

HOW MUCH DO YOU WANT? $_____________________________

REFERRAL FEE ENCLOSED (See fee schedule from email)

$_________________________________

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For Internal Use Only: (Please leave blank)

RecDt ____________ Pd ______________

DepDt __________ ClrDt ____________ SntDt _____________