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Online Placement Form

*Please note that this form is generally used for individual or low quantity placements. If you already have an account with us please just insert your client number and complete the debtor information. We accept placements in any format and can accommodate any type of file transfer.


Creditor Information

Client Number
Company
First Name
Last Name
Title
Address 1
Address 2
City
State
Zipcode
Phone #
Fax #
Email address


Debtor Information

First Name
Last Name
SSN #
Address 1
Address 2
City
State
Zipcode
Home Phone
Work Phone
Fax #
Email address
Amount Owed
Delinquency date
Client Acct #


Debtor History

No Response
Check Returned
Disputed
Mail Returned
Claims Inability to pay
Phone Disconnected
Additional Information
Image Verification
What kind of animal? Is this a monkey, dog, cat, or turtle?

 
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