Third Party Placement
YOUR COMPANY INFORMATION
Placement Type...:
Collection
Demand Letter
Placement Date..:
Company.........:
Region/Division.:
Address.........:
City/State/Zip..:
Contact name....:
Contact phone...:
Contact Email...:
Placement Amount:
DEBTOR INFORMATION
Debtor Name.....:
Account #.......:
Address.........:
City/State/Zip..:
Debtor Contact 1:
Phone...........:
Cell............:
Fax.............:
Email...........:
Debtor Contact 2:
Phone...........:
Cell............:
Fax.............:
Email...........:
SECURITY
Lien..............:
Yes
No
Guaranty..........:
Yes
No
UCC-1.............:
Yes
No
Promissory Note...:
Yes
No
Security Agreement:
Yes
No
Brief Account History (if applicable)
Special Instructions (if applicable)
Press SEND below to submit the above form in an email. PLEASE ATTACH A CREDIT APPLICATION AND STATEMENT OF ACCOUNT
