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Standard Placement Form
Please complete placement form,
including your customer's business name, address, phone number, amount they owe
your company, date of most recent invoice and any other information that you
feel would he helpful to us. Also include contact name if you know one. Please
send copies of invoices or statements, credit applications, checks, and any
other backup documentation that you may have.
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NOTE: Items marked by an asterisk ( * ) are required.
Information About You
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* Your Name
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Email Address
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Information About Your Company
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Account Number
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* Company Name
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* Address Line 1
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Address Line 2
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* City
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* State/Province
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* Zip/Postal Code
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* Country
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* Telephone Number
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Fax Number
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Information About Your Debtor
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* Company Name
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* Address Line 1
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Address Line 2
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* City
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* State/Province
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* Zip/Postal Code
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* Country
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* Telephone Number
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Fax Number
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Information About the Account
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* Account Owed
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* Currency
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If "Other", Please Specify
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Date of Last Sale or Service Rendered
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(mm/dd/yyyy) |
Invoice Number of Last Sale
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Date of Last Payment
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(mm/dd/yyyy) |
Information About Your Relationship with your debtor
Please check all that apply. This
information will aid us in understanding your situation and your
debtor.
They avoid contact (always in a
meeting, out of the office, etc.)
They will
not return calls/messages.
They dispute the
bill or request additional invoices.
There
is a personality clash and they won't communicate with you.
They broke their promise to pay sometime in the last
30 days.
You made concessions and they
still won't pay.
Are there any other details that you feel are relevant
to this account?
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