Enrollment Application

Organization Name *

Are you a decision maker pertaining to lead generation? *

Yes

No

How Many Employees are in your company? *

What type of leads are you looking for? *

B2B Intent-Based Leads

Email Marketing Campaigns

Content Syndication

Other: Other:

What are your target industry..? *

What type of leads are you looking for? *

North America

EMEA

APAC

LATAM

Global

Other: Other:

What’s your biggest challenge with lead generation currently?

+-

Which is your favorite chocolate..? As you have reach till here— I want to treat you with that when we meet. *

How many leads are you looking to generate per month? *

Monthly Budget Range You're Looking At *

Below $500

$500 – $1000

$1000 – $3000

$3000+

How soon you want to implement the project? *

less then a Month

1-3 Months

3-6 Months

Other: Other:

Phone / WhatsApp *

Name

Street Address

City

State

Zip Code

Federal Employer Identification Number (FEIN)

Description of Services

Entity 2

Name

Street Address

City

State

Zip Code

Federal Employer Identification Number (FEIN)

Description of Services

Please describe all business services offered by your business (This should include any service related or non-related to your Debt Settlement Business) *

0/200 characters

Business Ownership Details

Owner 1

First Name *

Last Name *

Email Address *

Office Phone Number *

Ownership % *

Owner 2

First Name

Last Name

Email Address

Office Phone Number

Ownership %

Owner 3

First Name

Last Name

Email Address

Office Phone Number

Ownership %

Owner 4

First Name

Last Name

Email Address

Office Phone Number

About Your Business

Ownership %

What vendor do you use to setup client special purpose accounts? *

Who is your outside counsel?

First Name *

Last Name *

Phone Number *

Email Address *

List all your active websites *

+-

How do you advertise? (check all that apply) *

TV

Print

Direct Mail

Radio

Internet

Other Other

Do you claim exemption from state law requirements? *

Yes

No

Please explain *

Average number of new clients enrolled per month (YTD) *

Average debt amount per new client (YTD) *

What is the total outstanding debt enrolled in your program? *

Currently, how many clients do you have enrolled in your program? *

Does your company negotiate the debts? *

Yes

No

Do you outsource your negotiations? *

Yes

No

To whom? *

Do you collect advanced fees from clients? *

Yes

No

Please describe how you acquire new customers. (Be sure to describe all channels or referral partners used to acquire leads) *

If you have partners that refer leads to you, do you pay for those leads? *

Do you solicit or cold call Consumers? *

Yes

No

How do you get the list of consumers to solicit? *

Please describe your overall growth plans for the next 2-3 years (For example, if you plan to expand your coverage to new states, grow your physical presence, or expand your offerings to Consumers, please list that here) *

What phone system do you use? *

Does it have call recording capability? *

Yes

No

Which business models do you use? *

Attorney Model

Advanced Fee Model

Performance-Based Model

Non-Profit Model

Other Other

Where Do You Do Business?

Please select "N/A" if you do not do business in a state *

	I do business in	Licensed	Exempt	N/A
Alabama	I do business in	Licensed	Exempt	N/A
Alaska	I do business in	Licensed	Exempt	N/A
Arizona	I do business in	Licensed	Exempt	N/A
Arkansas	I do business in	Licensed	Exempt	N/A
California	I do business in	Licensed	Exempt	N/A
Colorado	I do business in	Licensed	Exempt	N/A
Connecticut	I do business in	Licensed	Exempt	N/A
Delaware	I do business in	Licensed	Exempt	N/A
Florida	I do business in	Licensed	Exempt	N/A
Georgia	I do business in	Licensed	Exempt	N/A
Hawaii	I do business in	Licensed	Exempt	N/A
Idaho	I do business in	Licensed	Exempt	N/A
Illinois	I do business in	Licensed	Exempt	N/A
Indiana	I do business in	Licensed	Exempt	N/A
Iowa	I do business in	Licensed	Exempt	N/A
Kansas	I do business in	Licensed	Exempt	N/A
Kentucky	I do business in	Licensed	Exempt	N/A
Louisiana	I do business in	Licensed	Exempt	N/A
Maine	I do business in	Licensed	Exempt	N/A
Maryland	I do business in	Licensed	Exempt	N/A
Massachusetts	I do business in	Licensed	Exempt	N/A
Michigan	I do business in	Licensed	Exempt	N/A
Minnesota	I do business in	Licensed	Exempt	N/A
Mississippi	I do business in	Licensed	Exempt	N/A
Missouri	I do business in	Licensed	Exempt	N/A
Montana	I do business in	Licensed	Exempt	N/A
Nebraska	I do business in	Licensed	Exempt	N/A
Nevada	I do business in	Licensed	Exempt	N/A
New Hampshire	I do business in	Licensed	Exempt	N/A
New Jersey	I do business in	Licensed	Exempt	N/A
New Mexico	I do business in	Licensed	Exempt	N/A
New York	I do business in	Licensed	Exempt	N/A
North Carolina	I do business in	Licensed	Exempt	N/A
North Dakota	I do business in	Licensed	Exempt	N/A
Ohio	I do business in	Licensed	Exempt	N/A
Oklahoma	I do business in	Licensed	Exempt	N/A
Oregon	I do business in	Licensed	Exempt	N/A
Pennsylvania	I do business in	Licensed	Exempt	N/A
Rhode Island	I do business in	Licensed	Exempt	N/A
South Carolina	I do business in	Licensed	Exempt	N/A
South Dakota	I do business in	Licensed	Exempt	N/A
Tennessee	I do business in	Licensed	Exempt	N/A
Texas	I do business in	Licensed	Exempt	N/A
Utah	I do business in	Licensed	Exempt	N/A
Vermont	I do business in	Licensed	Exempt	N/A
Virginia	I do business in	Licensed	Exempt	N/A
Washington	I do business in	Licensed	Exempt	N/A
West Virginia	I do business in	Licensed	Exempt	N/A
Wisconsin	I do business in	Licensed	Exempt	N/A
Wyoming	I do business in	Licensed	Exempt	N/A
Washington DC	I do business in	Licensed	Exempt	N/A

List your fees to the client (if you charge different fees per state, please list them out clearly) *

Organization Overview

Do you have a Compliance Officer? *

Yes

No

Who has responsibility in your organization for Compliance? *

Do you plan on hiring a Compliance Officer as a result of offering this product? *

Yes

No

Please list any and all active or settled litigation in the last 3 years (Civil or Criminal) or enforcement actions against your company (Enforcement actions can be from a state or federal regulator, state AG, or DOJ) *

Has company, including the principal(s) and controlling person(s) of the entity with 10% or more ownership interest in the entity, ever been subject to enforcement action (including investigation, inquiry, revocation of license, settlement, or lawsuit) by a state or federal government agency? *

Yes

No

Has company, including the principal(s) and controlling person(s) of the entity with 10% or more ownership interest in the entity, ever been subject to material litigation alleging consumer fraud or noncompliance with consumer protection laws? *

Yes

No

*

I CERTIFY THAT THE INFORMATION SUPPLIED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND I GIVE LENDINGUSA, LLC AND THEIR ASSIGNS THE RIGHT TO INVESTIGATE CREDIT AND TO VERIFY THE INFORMATION CONTAINED IN THE APPLICATION.

Title *

Full Name *

Signature *

clear

Code of Conduct

DSC Merchant shall comply with all federal and state laws regulating credit advocacy and debt relief services, including, but not limited to, the 2010 FTC Rules for debt relief providers.

The FTC Rules, among other things, only permit fees to be charged after:

A written agreement is entered with a consumer;
A settlement or result is obtained; and
The consumer authorizes and accepts such result.

Any DSC that is charging Advance Fees for debt relief services will not be eligible for enrollment in LUSA’s DSC Merchant Program.

Communications with clients and the public shall be honest and truthful.
Agreements and services shall be conducted in good faith.
DSC Merchants shall advocate solely on behalf of the client and shall not accept compensation, fair share, contributions or donations from creditors.
Fees charged for services provided to clients shall be fair and reasonable.
Representations regarding the services and potential outcomes of the service that DSC Merchant provides to consumers shall be fair and accurate.
Estimates used in setting up a program for consumers such as the total cost and program length shall be based on historical and substantiated data.
DSC Merchants shall clearly and conspicuously disclose both the risks as well as the benefits of credit advocacy to individuals enrolling in programs.
DSC Merchants shall clearly and conspicuously explain what fees are charged for their services, how the fees are charged and when such fees are earned.
DSC Merchants shall protect the privacy of personal information of clients and prospective clients.
In addition to the above, DSC Merchants shall abide by the rules and program guidelines contained in LUSA’s DSC Merchant Program.

On behalf of the below listed DSC Merchant, i affirm that we commit to the above Code of Conduct for the DSC Merchant’s actions and conduct in the operation of our company. *

I understand that a violation of the code of conduct is grounds for suspension or expulsion from the LUSA DSC Merchant Program.