COLLECTION FORM

Printable View Collection Services Immediate Placement Request Please accept the following account for immediate Collection Online Instructions: Carefully complete all pertinent information. We will verify receipt of the account. Debtor Information Account Name DBA Contact Name Telephone Number (including area code) Address P.O. Box City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Zip Code Amount of Claim $ Please include copies of invoices or other documents supporting claim amount. Type of Claim: Commercial Account Consumer Account Does your customer agreement provide for addition of collection fees to claim amount? Yes No Does your credit application or contract allow for interest to be charged? Yes No   If so, how much? Does your customer agreement provide for a personal guarantee? Yes No I agree to pay the prevailing Collection Rate in effect at the time of placement. Yes No Notes: Creditor Information Company Name Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Zip Code Telephone Number Fax Number (Including area code) Email Signature Date   About Us | Contact Us Terms of Use | Privacy Statement © 2006 NACM Great Lakes An Affiliate of National Association of Credit Management