Fields indicated with an asterisk (*) are required before you will be able to submit
your placement:

Business Name:*

Contact (Last Name, First Name):

Address:*

City:*

State:*

Zip:*

Country
(if other than USA):

Phone:*

(e.g. 847-763-0763)

Fax:

(e.g. 847-763-0763)

Email:

(e.g. info@yahoo.com )

Web Site

Amount Owed:*

Last Payment Date:

Last Invoice Date:*

Customer No:

Collection History and/or Comments

The following will be forwarded to Credit Decisions Intl via:

Statement

Invoice

Guaranty

NSF Check

Credit Report

UCC1

Signed Credit Application

Collection Fee Allowed ?

Yes

Interest Rate Allowed :

Yes

Other (Describe Below):

	Please Issue 10 Day Free Demand
	Immediate Placement

Please proceed with collection of the above account subject to your rate schedule.
We shall report promptly all payments and communications received from the debtor.

Note: Should it become necessary to forward this claim to an attorney for collection,
you are hereby authorized to do so.

You are hereby authorized to endorse for deposit and collection in our name and in
our behalf, remittances received on this account.

Client No:

Telephone:

(e.g. 847-763-0763)

By:

Creditor:

E-Mail:*

(e.g. xyz@yahoo.com )

Thank You!

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