CollectionAgency 

TRANSFORM YOUR LOSSES INTO PROFITS!

TOLL FREE: 1-234 567-7890

Online Account Placement

Please provide us with the following requested information

If you wish to place multiple claims, please simply e-mail us and provide us with all your information along with all the information on the debtors that you wish to place. This way you won't have to enter your company information each time you place a new account.

Name: 

Company:

Address 1:

Address 2:

City: 

State:

Zip Code:

Country:

Phone:

Fax:

Email:

Name: 

Company:

Address 1:

Address 2:

City: 

State:

Zip Code:

Country:

Phone:

Fax:

Email:

Amnt Owed:

Acct: #:

Comments:

Your company information:

Debtor information: