Collection Account Placement Form

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):

"It helps me decide on whether or not I want to take the risk of selling

For more information,
Email: assn@nacmservices.com

or . . .call us . . . . no waiting
you get real, live people!
1-800-593-0907
The NACM MidAmerica staff is
eager to serve your needs.

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