Placement Request Form

Urgent Action Final Notice

     (please mark which service you prefer)

Debtor Information

Account Name: DBA:
Contact Name: Phone #:
Address: Fax #:
City, State, Zip: E-mail:


Please include copies of invoices or other documents supporting claim amount

Type of Claim: Commercial Account Consumer Account
Does your customer agreement provide for the addition of collection fees to the claim amount? Yes No
Does your credit application or contract allow for interest to be charged? Yes No
I agree to pay the prevailing Collection rate in effect at the time of placement. Yes No

Creditor Information

Company Name:
Contact Name:
Address: Promo Code:
City, State, Zip: E-mail:
Phone: Fax:
Signature: (print your name) Date: