Account Placement Form

P.O. Box 42491 Portland OR 97242 (503) 233-2440 (503) 233-7253-FAX (800) 377-2671 Home Account Placement Recent Press Testimonials History Commitment To You Mission Statement Rates Links Contact Us

Your Email:    Your Company Information   Person Placing Account: Company Name: Street Address 1: Street Address 2: City, State, Zip: Phone Number: FAX Number:    Your Customer/Debtor:   Debtor Name: Contact Person 1: Contact Person 2: Street Address 1: Street Address 2: City, State, Zip: Phone Number: FAX Number:    Account Details Account Number: Invoice(s) or Itemization: Account Balance US$: Contract Late Fees/Interest US$: Date of Last Payment: Additional Docs Will Be Sent By: None USPS Mail FAX E-Mail Attachment Have You Sent A 10-Day Demand Letter: Yes No Do You Have Their Credit Application: Yes No Do You Have A Personal Guarantee Yes No Special Comments or Instructions:

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