Full Name

Address 1

Address 2

City

State

Zip Code

Phone Number

Email Address

Are you looking to collect from a business(s) or individual(s) I am looking to collect from a business I am looking to collect from an individual. I am looking to collect from both businesses and individuals.

Approximately how much money are you currently looking to collect? $500 - 1,000 $1,000 - 5,000 $5,000 - 10,000 $10,000 - 50,000 $50,000 - 100,000 $100,000 - 500,000 $500,000 - 1,000,000 $1,000,000+

Approximately how many accounts are you looking to collect on? 1 2-5 6-10 11-25 26-49 50+

Approximately how long, on average, have the accounts been outstanding? Less than 2 months 2-4 months 4-6 months 6-12 months More than 1 year More than 2 years

Do you have contact information for the accounts or debt you are looking to collect on? Yes No Not Sure

Please provide any additional details regarding the accounts or debt you wish to collect on.

Description of client and accounts being assigned.