E-mail Address: *                      
Delinquency Date
Last Date of Service
Total Amount Referred
Business (Debtor)
Business Street Address
Business Mailing Address
Phone
Type of Business
Federal ID#
Type of Ownership Corporation
Partnership
Individual Proprietorship
Names and Home Addresses of Officers, Partners or Owners
SSN#
Banks
Account #
Account #
Please Check the Appropiate Boxes Dispute
Broken Promise
Secured (Bond, Lien, UCC)
Personal Guarantee
NSF Check
Prev Handled/ATT or Collection
Out of Business
Skip
Over 1 Year/Date of Last Invoice
Ignored
Creditors Name
Date
Address
Phone
Authorized By
Title

* Required

Please forward a copy of the debtors credit application and final invoice with this form.

The above account is submitted for commercial collection within the terms of the agreement with your company. Commission on this account is to be paid to MERCHANTS CREDIT BUREAU based on payments received from the debtor.

Withdrawn accounts are subject to payment of commission.

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