Briefly describe the type of accounts to be sent into collection:
    Anticipated volume to be placed:
    Dollar Amount:

    Number of Accounts:

    Future Placement Frequency:

    Previous collection efforts on these accounts: (What has been done to collect on these accounts?)
    Average age of accounts; (how many days past due)?

    What information/backup do you have for the accounts? (Contracts, statements, original signed documents, etc.) What computer system is the information stored on?
    Contact Information
    Name:

    Title:

    Company:

    Address:

    City:

    State:

    Zip:

    Email:

    Website:

    Phone:

    Fax:

    Please enter the 4 characters below