PLACE AN ACCOUNT WITH NATIONAL SERVICE BUREAU
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Note: All fields are required.
Creditor:
Company:
Address:
Name:
City:
Phone:
State:
E-mail:
Zip:
Fax:
Client #:
Debtor Information
Debtor:
Address:
Contact Name:
City:
Title:
State:
Amount: ($)
Zip:
Add Interest: ($)
Main Telephone Number:
Total Amount Due: ($)
Alternate Number:
Date of Original Invoice:
E-mail:
Date of Last Payment:
Client Reference #:
Legal Entity:
Corporation
Sole Proprietorship
Joint Venture
Partnership
Second Placement:
Judgment:
Yes
No
Yes
No
Personal Guarantee:
Yes
No
Additional Addresses and phone #'s:
Comments:
Attention:
PLEASE REPORT ALL PAYMENT AND COMMUNICATIONS PROMPTLY.
LEGAL ACTION SHALL NOT BE INSTITUTED WITHOUT APPROVAL AND AUTHORIZATION.
WITHDRAWAL OF CLAIMS WILL BE SUBJECT TO OUR STANDARD FEES.
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