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Collection Placement Form
mvisconti
2019-03-03T22:08:14+00:00
Collection Placement Form
Your Company Name
Your Name
First
Last
Phone
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Business Debtor Name
Contact Name
First
Last
Position Held at Company
Phone
Email
Address of Business
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Last Invoice
MM slash DD slash YYYY
Business's Website
Amount Due: Principle
Amount Due: Interest
Amount Due: Total
Bank Name:
Bank Account Number:
Does this account involve a dispute? If so, please explain:
Please Provide Backup (if available)
Credit Application
Personal Guarantee
Purchase Order / Bill of Lading
Judgement
Bad Check (copy)
Experience with customer
Debtor Avoiding Calls
Refuse to Return Calls
Broken Promises
Done Everything We Can. Will Not Pay.
Bad Check
File
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Select files
Max. file size: 50 MB.
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