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*Amount to be
collected, Currency:
USD Other*
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*Your Account Number
*Last Payment Date
Oldest
invoice
(Skip this if providing invoice details below. Also note: 40% if over 1 year).
Yes No
Personal guarantee?
Yes No
NSF check?
Yes No
Second placement? (40%)
Yes No
Disputed?
Dispute details:
Additional information, comments, or instructions:
Invoice details
Please complete the following if not faxing or e-mailing invoice(s) to us:
*Invoice number********
Date************
Amount************PO number
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By submitting this form the Creditor acknowledges having read and
agreed to the
Terms and Conditions.
*Please check this box:
I / We have read and agree to your terms and conditions.
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