.............Client Information Form:

V E R Y   I M P O R T A N T !!!

 Please be sure to fill in all the fields as best you can. Keep in mind we can only effectively help you
and do our job, if we have all the proper information, which only you are able to provide.

Also know, that all of your information is absolutely confidential
and we will never disclose all or any part of it!

 (ALL fields marked with an Astrik "*" are required fields, all others are optional fields)
.
Personal Info:
.
First / Middle / Last -Name: * * *
Street / Mailing -Address: *
City / State / Zip-Code: * * *
Phone / Home/Cell -Phone# / Email: *
Creditor #1>> Info:
Name of the Company: *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Available Current Documents:  Yes No

 Of what nature is the document?
 (choose from the selection below)

*

If other, please describe:
*
Collection Agency #1>> Info:
Name of the Company/
Agents Name/Your Account #:		 * * *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Do you have anything in writing?  Yes No
If so, what? *
How many harassing calls
do you get?		 *

 
Creditor #2>> Info:
Name of the Company: *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Available Current Documents:  Yes No

 Of what nature is the document?
 (choose from the selection below)

*

If other, please describe:
*
Collection Agency #2>> Info:
Name of the Company/
Agents Name/Your Account #:		 * * *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Do you have anything in writing?  Yes No
If so, what? *
How many harassing calls
do you get?		 *
Creditor Info #3>>:
Name of the Company: *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Available Current Documents:  Yes No

 Of what nature is the document?
 (choose from the selection below)

*

If other, please describe:
*
Collection Agency #3>> Info:
Name of the Company/
Agents Name/Your Account #:		 * * *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Do you have anything in writing?  Yes No
If so, what? *
How many harassing calls
do you get?		 *

 
Creditor #4>> Info:
Name of the Company: *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Available Current Documents:  Yes No

 Of what nature is the document?
 (choose from the selection below)

*

If other, please describe:
*
Collection Agency #4>> Info:
Name of the Company/
Agents Name/Your Account #:		 * * *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Do you have anything in writing?  Yes No
If so, what? *

How many harassing calls
do you get?		 *

 
Creditor #5>> Info:
Name of the Company: *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Available Current Documents:  Yes No

 Of what nature is the document?
 (choose from the selection below)

*

If other, please describe:
*
Collection Agency #5>> Info:
Name of the Company/
Agents Name/Your Account #:		 * * *
Address / Street / Mailing: *
City / State / Zip-Code: * * *
Phone- Fax -Number: * *
Do you have anything in writing?  Yes No
If so, what? *
How many harassing calls 
do you get?		 *

 

!If You have more than these 5 Bills/Invoices to cover,
you must call us at 800-246-3038!

.............................