Placement Form

Type of debt

Debtor Account # (your file# for this account)

Debtor Company Name
*Debtor Contact*
*Date of Transaction*
Debtor Address Debtor City,State,Zip
*Debtor Telephone*
*FAX*
Comments: Briefly describe the nature of the collection problem and the circumstances involved .	I have read and understand the terms and conditions of the service schedule. I authorize American Credit Systems, Inc. to proceeed with collection activities based upon terms and charges indicated. *must check box*

Client Name:

Client Address:

Client city,state,zip Client email

Client Phone:

Client Contact: