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Toll Free 866-460-7898
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WEB PLACEMENT FORM

Your Company Info     * required information  

Client #

* Company 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 or 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

Option: Attach a file:


* Check box to authorize AIP Solutions to initiate collection activity on the above account.  

 

FOR OFFICE USE ONLY

Assigned to Collector #:  

Rate: %

Prime Yes No    PHIN Yes No

 

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