Toll free: 1-234-567-7890

COLLECTION AGENCY 

PLEASE PROVIDE US WITH THE FOLLOWING REQUESTED INFORMATION

ONLINE ACCOUNT PLACEMENT

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.

YOUR COMPANY INFORMATION:

DEBTOR INFORMATION:

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: #:

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