| FULL LEGAL NAME OF DEBTOR COMPANY: |
|
| TRADE STYLE OR BUYING NAME: |
|
| AMOUNT TO BE COLLECTED: |
|
| ADDRESS: |
|
| COMPANY TYPE: |
Proprietor
Partnership
Corp |
| DATE OF LAST PAYMENT: |
|
| PRINCIPAL: |
|
| TELEPHONE: |
res:
bus:
|
| PRINCIPAL: |
|
| TELEPHONE: |
res:
bus:
|
| BANKING INFO: |
account#:
location:
|
| |
NSF cheques:
Stop PMTS:
|
| INVOICE FORWARDED:
CREDIT APPLICATION ON FILE:
|
| COMPANY TYPE: |
Retail
Wholesale
Manufacturer
Other |
| NAME OF OTHER SUPPLIERS TO DEBTOR COMPANY: |
|
| EXPLAIN AVAILABLE DOCUMENTATION: |
|
| Client Information |
| Delinquent Account Listing Sheet. You are hereby authorized to proceed with the collection of the accounts listed above, which we certify to be legally owing and unpaid. Any payment received by us, or merchandise accepted by us with your consent is considered to be payment and will be reported to you. |
| CLIENT'S NAME: |
|
| ADDRESS: |
|
| CONTACT NAME: |
|
| TYPE OF BUSINESS: |
|
| PHONE: |
|
| FAX: |
|
| |
Existing Client:
Client Rep:
|
|
