CURE™ Placement Form:

Please Check:
First Time Client
Please Contact Me

FROM:
Your Name:
E-mail:
Member #:
Company:
Phone:
Street:
City/State/Zip:

Our Customer's Information:

Company Name:
Address:
City/State/Zip:
Business Phone:
Home Phone:
Fax:
Principal:
Amount to Collect:

Type of Organization:

Proprietorship
Partnership
Corporation
LLC

Brief history of the account including any disputes:

List summary of documents to support the claim
(statements, invoices, NSF check, etc):