Section A
-- Please fill in the information below.  All fields in bold are required--
 

First Name

Last Name

Address

City

State

select Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home Phone

Date of Birth
(dd-mm-yyyy)

Social Security Number
(999-99-9999)

E-mail Address

How did you hear about us?

Section B
-- Fill out bank information --

I authorize American Health and Financial to draft $99.00 from my bank account and auto deduct
or draft my monthly payments of $39.00. This payment will be scheduled on the monthly
anniversary of this contract. (i.e. 01/06/02, 02/06/02, 03/06/02)
 

Section C
-- Terms and Agreement --

A. This Membership Agreement between American Health and Financial, and the undersigned "Member" (refers to both in case of a couple) is for the purpose of purchasing Membership in American Health and Financial Premier Membership Group. Membership will grant the ?Member? access to Members only Debit MasterCard, Health Care Discount Plans, Proven Debt Consolidation Programs, Debt Settlement plans (reduce balances up to 80%), Self Paced Credit repair program, Paralegal services and all future benefits. AHF Self paced Legal Credit Repair System uses only techniques that are in accordance with federal and state laws. B. The "Member" understands that there will be a one time case set up fee of Ninety-nine Dollars ($99.00) and a continuous monthly fee of Thirty-Nine Dollars ($39.00) for the Membership Dues, or One Hundred Forty-Nine Dollars ($159.00) and a continuous monthly fee of Fifty-Nine Dollars ($59.00) for the Spouse Membership, billed at the time this Agreement is signed. The "Member" understands and agrees that a fee of $39.00 for the Standard Membership or $59.00 for The Spouse Membership will be due, and that this fee will be charged on a continuous monthly basis until cancelled. The monthly dues fee is for continued access to all listed benefits. C. If the "Member" decides to cancel the "Membership" they may do so at anytime with written or verbal notice. You may cancel this Agreement without penalty or obligation at any time before midnight of the third (3rd) business day after the date on which you signed the contract. To cancel you must send an email to Support@HealthandFinancial.com or call 1-210-399-5399 and receive a cancellation code. D. No guarantee nor warranty can be given for the outcome of any Debt Consolidation, Debt Settlement plan, or Self Paced Credit Repair. Under no circumstances shall the company, its agents nor owners be liable for any consequential damages. Damages shall never exceed the amount the member has paid to AHF. Any claim shall be arbitrated initiated by written demand within 1 year from the event filed under the American Arbitration Rule located in South Texas or will be forever barred. All contracts including this should be reviewed by a lawyer of your choice before signing.

I agree and understand what I am signing, and acknowledge that I have received a copy of the General Terms and Conditions and all of its provisions and attachments by printing or saving this document.

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus that gather and sell information about your creditworthiness to creditors, employers, landlords, and other businesses. The FCRA gives you specific rights, which are summarized below. You may have additional rights under state law. For more information, go to www.ftc.gov/credit, or write to: Consumer Response Center, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. You must be told if information in your file has been used against you. Anyone who uses information from a consumer reporting agency to deny your application for credit, insurance, or employment – or take another adverse action against you – must tell you and give you the name, address, and phone number of the agency that provided the information. You can find out what is in your file. At any time, you may request and obtain your report from a consumer reporting agency. You will be asked to provide proper identification, which may include your Social Security number. In many cases the report will be free. You are entitled to free reports if a person has taken adverse action against you because of information in a report; if you are the victim of identify theft; if you are the victim of fraud; if you are on public assistance; or if you are unemployed but expect to apply for employment within 60 days. In addition, you are entitled to one free report every twelve months from each of the nationwide credit bureaus and from some specialized consumer reporting agencies. See www.ftc.gov/credit for details about how to obtain your free report. You have a right to know your credit score. Credit scores are numerical summaries of a consumer’s creditworthiness based on information from consumer reports. For a fee, you may get your credit score. For more information, click on www.ftc.gov/credit. In some mortgage transactions, you will get credit score information without charge. You can dispute inaccurate information with the consumer reporting agency. If you tell a consumer reporting agency that your file has inaccurate information, the agency must take certain steps to investigate unless your dispute is frivolous. For an explanation of dispute procedures, go to www.ftc.gov/credit. Inaccurate information must be corrected or deleted. A consumer reporting agency or furnisher must remove or correct information verified as inaccurate, usually within 30 days after you dispute it. However, a consumer reporting agency may continue to report negative data that it verifies as being accurate. Outdated negative information may not be reported. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need as determined by the FCRA -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. Identity theft victims and active duty military personnel have additional rights. Victims of identity theft have new rights under the FCRA. Active-duty military personnel who are away from their regular duty station may file “active duty” alerts to help prevent identity theft. For more information, visit www.ftc.gov/credit. Your consent is required for reports that are provided to employers. A consumer reporting agency may not give out information about you to your employer, or potential employer, without your written consent. Blanket consent may be given at the time of employment or later. You may choose to remove your name from consumer reporting agency lists for unsolicited credit and insurance offers. These offers must include a toll-free phone number you can call if you choose to take your name and address off lists in the future. You may opt-out at the major credit bureaus by calling 1-800-XXXXXXX. You may seek damages from violators. If a consumer reporting agency, a user of consumer reports, or, in some cases, a furnisher of information to a consumer reporting agency violates the FCRA, you may sue them in state or federal court. The FCRA gives several federal agencies authority to enforce the FCRA: TO COMPLAIN AND FOR INFORMATION: PLEASE CONTACT: Consumer reporting agencies, creditors and others not listed below Federal Trade Commission Consumer Response Center - FCRA Washington, DC 20580 1-877-382-4367 (Toll-Free) National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743 Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693 Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Office of Thrift Supervision Consumer Programs Washington, DC 20552 800-842-6929 Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-518-6360 State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC 20429 800-934-FDIC Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Department of Transportation Office of Financial Management Washington, DC 20590 202-366-1306 Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051 We do not have a restriction on cancellation and you may cancel your service with our company at any time.

I agree and understand what I am signing, and acknowledge that I have received a copy of Consumer Credit File Rights by printing this document.