Commercial Account Referral

Please fax a copy of the Debtor's credit application and final invoice when submitting this form. The account is submitted for commercial collections within the terms of agreement with your company. Commissions on this account is to be paid to Merchants Credit Bureau based on payments recieved from debtor. Withdrawn accounts are subject to payment of commissions. (706)823-6315 Fax


E-mail Address: *
Delinquency Date
Total Amount Referred
Business (Debtor)
Business Street Address
Business Mailing Address
Phone
Type of Business
Federal ID#
Type of OwnershipCorporation
Partnership
Individual Proprietorship
Names and Home Addresses of Officers, Partners or Owners
SSN#
Banks
Account #
Account #
Please Check the Appropiate BoxesDispute
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

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