Fax Line 866-867-1084
Toll Free 866-460-7898
8428 E. Shea Blvd., Suite #101
Scottsdale, Arizona 85260

FAX PLACEMENT FORM

Your Company Info    * required information

Client #

* Name:
 		* Your Name:
  

Sales #

* Address: * City:
* State:

* Zip:

* Phone: Fax:

Date:

* Your Email Address:

Debtor Information
* Debtor Company Name:
 

Your Reference #

* Address: * City:
* State:

* Zip:

* Phone:
 Alt. Phone:
 Fax:
* Contact Name:

* Date of Last Sale:

*Service of Product Provided:

*Date of Last Payment:
* Amount Due: Add-ons:

TOTAL:

Comments: 
 

BACKUP
* Personal Guarantee Yes No  * NSF Check Yes No  * Credit Application Yes No

I authorize AIP Solutions to initiate collection activity on the above account.
Signature:
 Print Name:
 Date:

Please fill in this form, print it and fax to 866-867-1084

FOR OFFICE USE ONLY
Assigned to Collector #:    Rate: %      Prime Yes No    PHIN Yes No

Back to AIP Solutions Home Page

© 2003-2010 AIP Solutions