Placement

Check box for collection service needed:
Immediate Placement Service
(member & non-member) 		10 Day Final Demand
(member & non-member) 		30 Day Pre-Collect
(member only for free pre-collect)
DEBTOR INFORMATION
Account Name*: DBA:
Contact Name*: Phone Number*:
Including Area Code
Address*: PO Box:
City*: State*: Zip Code*:
Ammount of Claim*: $
Type of Claim*:     Commercial Account     Consumer Account

Does your customer agreement provide for addition of collection fees to claim amount?*:

   Yes     No  

Does your credit application or contract allow for interest to be charged?*:

   Yes     No  
Is so, how much?*:   %

I agree to pay the prevailing Collection Rate in effect at the time of placement.*:

   Yes     No  

Notes:

Please check any of the following that apply.
NSF Dispute Promissory Note Bankruptcy Personal Guarantee
CREDITOR INFORMATION
Contact Name*: Fax Number*:
Including Area Code
Company Name*: Phone Number*:
Including Area Code
Address*: PO Box:
City*: State*: Zip Code*:
Email:
How will documentation be submitted?*:     Email       Fax     Mail  
Date submitted to NACM GLR*: NACM GLR Member #*::