Members Claim Placement Form

Your current collection services agreement remains in effect.

* Indicates mandatory fields

Member Info

*Company Name:

*Company Contact:

*Client Account Number:

Street Address:

City:

Province/State:

Country:

Postal Code/ZIP:

Telephone: (area code required)

Fax: (area code required)

Email address:

Debtor Information

Debtor Name:

Debtor Street Address:

City:

Province:

Country:

Postal Code:

Telephone: (area code required)

Fax: (area code required)

Email:

Contact Name:

Balance of Account (Amount for Collection): $

Currency:

CAN US

Debtor Bank:

Debtor Account #:

Debtor Date of Birth:

Social Insurance #:

Next of Kin:

Place of Employment:

Place directly into collections

Send the following letter

  Standard Approach
  Goodwill Collection
  Specify

  Early Reminder
  Standard Demand
  10 Day Specific Demand
  Dispute Reconciliation Notice
  Goodwill Payment Arrangement (Crd)
  Goodwill Continued Business
  NSF Recovery (Criminal Code)
  Broken Promise
  Unreturned Phone Call

FAX	COURIER
Regular MAIL	Registered E-MAIL
Note: All letters are mailed unless otherwise requested.
ENGLISH	FRENCH
(If language preference is not selected, English letters will be sent.)
Would you like to receive a faxed copy of your legal demand letter? yes no

Additional Comments: