Sterling Phillips & Associates

 
Account Placement Form

 

Client Name

Client Phone #

Client Contact Person

Debtor Information :

Debtor Name

DBA/AKA
     

Address

City

State

Zip 

Debtor Ref #

Phone #1

Phone #2

Fax #

Primary Contact

Second Contact

Date of Invoice
to

Net placement $

Service charge $

Collection charge $

Total Placement $

Last Payment date

Debtor's bank

Branch

 

NSF Check Information:

$ Date

$ Date

$ Date

$ Date

 

 

Do you have:

Credit Application:
yes no

Copy of any NSF's:
yes no

Statement:
yes no

Invoices:
yes no

Personal Guarantee:
yes no

 

 

Miscellaneous Information about debtor:


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4739 Utica, Suite 212
Metairie, Lousiana 70006
Phone 800-375-5773
Fax 504-887-0701

 

© 1997 Sterling Phillips & Associates