Please fill in the blanks for the class registration form. When finished, please click the "continue" button. Thank you.

First Name of Student:  (Required) A value is required.
Last Name of Student:  (Required) A value is required.
Address 1:  (Required) A value is required.
Address 2:  
City:  (Required) A value is required.
State:  (Required)
Zip:  (Required) A value is required.Invalid format.
Phone Number:  (Required) A value is required.
Email Address:  (Required) A value is required.Invalid format.
Bankruptcy Case Number:  (Required) A value is required.  ##-#####    #######
Bankruptcy Case Number Example: 08-BK-12345-MJ
The numbers in red are the ONLY numbers required (No dashes, periods or commas)
State filing bankrupcty in: (Required)
County: (Required)
Spouse Information Required If Filing Jointly
Spouse First Name:  
Spouse Last Name:  
Spouse State:  
Phone Number:  
Spouse Email Address (if different from above):  
Spouse Bankruptcy Case Number:     ##-#####    #######
Bankruptcy Case Number Example: 08-BK-12345-MJ
The numbers in red are the ONLY numbers required (No dashes, periods or commas)
   
Attorney Name: A value is required.
Attorney Email Address: A value is required.Invalid format.
   
Payment Amount:


I certify that the information I am providing to Advantage Credit Counseling Service, Inc. is true, correct and made in good faith. I also certify that I
personally will complete the pre-discharge bankruptcy education course. I understand that knowingly making a false statement or fraudulent statement or
misrepresentation about my identity or completion of the course is a violation of the requirements of federal law.