PLACEMENT OF NEW BUSINESS  - FAX / MAIL-IN FORM

Client Name: __________________________________________________________

Address: ______________________________________________________________

_____________________________________________________________________

Phone: _______________________   Fax: ______________________

Debtor Name:  _________________________________________________________

Debtor last known address_____________________________________________

         ______________________________________________________________

** IMPORTANT ** Please include SS# if possible

Social Security #(s)______________________________________________________

Last known Home Phone _________________________________________________

Last known Place(s) of Employment & Phone #________________________________       

Balance Placed______________ Date debt incurred or last charge date______________

Date last paid____________________  Report to Credit Bureau _______Yes ______No

Relatives or other contact information  _______________________________________

_______________________________________________________________________
 
Additional Information_____________________________________________________

Client Representative signature ______________________________________________

Date____________       Permission to pursue legal action?  ______Yes   ______No

Interest collected will be retained by Northwest Collectors to help defray the cost of collection. It is understood that Northwest Collectors has the authority to start suit on this account if necessary. Northwest Collectors advances the costs of any such action. Monies due you from collections made will be paid after deducting these costs. Northwest Collectors does not guarantee collection of any assigned account.

PLEASE SEND A SIGNED COPY OF THE ORIGINAL AGREEMENT SIGNED BY THE DEBTOR, SHOWING WHERE COLLECTION FEES CAN BE ADDED (IF ANY). Please send any additional supporting documents also.

Collection fees may be added to an account, only when it is specifically stated in the original agreement signed by the debtor. It is not sufficient to send a letter stating that if the debt isn't paid within a certain amount of time that collection fees will be added.

If you do not have the statement under the default terms of your agreement, I would suggest that you add that collection and/or attorney's fees will be added to past due accounts.

Please send us a legible copy of the signed document when you send us your placements so we can have them on file and won't need to ask for any more paperwork should we pursue legal action. Also it would be great just to have an original blank copy for our files.

If you have any questions, please feel free to call Kelly at 541-3993 or 1-888-547-3993.