COLLECTION REQUEST FORM

This form is for Existing Clients Only

An Alternative to completing this form is to FAX your own standard form.

Please complete as much information as possible.

Your Customer ID code:
Your Company Name:
Your Name:	* Required
Your PhoneNo:	* Required
Debtors Name:
Debtors Customer Number:
Debtors Company Name:
ACN, ABN, ARBN:
Debtors Last Known Address:
State:
Postcode:
Last Known Phone No:
Debtors Last Known Employer:
Last Known Work No:
Last Known Mobile No:
Other Numbers:
Are there any Guarantors. Details Please:
Original Amount:
Amounts Paid to Date:
DEBT AMOUNT:
Nature of Debt:
Further Information: Please include any details as to Why the customer is refusing to pay, Disputes etc