Commercial Account Placement Form
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1Commercial Account Placement Form
For Accounts on a Company
From: _____________________________________ Submitted By: _______________________
______________________
Your Company Name
Your Name
Your Telephone
Your Eastern Client Number: ________________ Your Email: ____________________________________________________
Please ensure we are notified of any payments made to your office. Payments can be reported to us by phone, email, or fax.
ACCOUNT NAME: ______________________________________________________________________________________________________________________
Company Name
Address: ________________________________________________________________
Postal Code: _______________________
Mail Returned: No q Yes q
Mailing Address: _________________________________________________________
Postal Code: _______________________
Mail Returned: No q Yes q
Phone: ____________________________________________________________
Website: __________________________________________________________
Email: _________________________________________________________________________________________________________________________________
Company Legal Name: ___________________________________________________________________________________________________________________
Contact Person: ____________________________________________________
Company Owner: ___________________________________________________
AMOUNT DUE: __________________________
Account #: ________________________________
Charge Interest: No q Yes q If yes, specify rate: _____
Date of Invoice: ___________________________________________________
Date of Last Payment: _____________________________________________
MM/DD/YYYY
MM/DD/YYYY
Other pertinent details: ___________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
ACCOUNT NAME: ______________________________________________________________________________________________________________________
Company Name
Address: ________________________________________________________________
Postal Code: _______________________
Mail Returned: No q Yes q
Mailing Address: _________________________________________________________
Postal Code: _______________________
Mail Returned: No q Yes q
Phone: ____________________________________________________________
Website: __________________________________________________________
Email: _________________________________________________________________________________________________________________________________
Company Legal Name: ___________________________________________________________________________________________________________________
Contact Person: ____________________________________________________
Company Owner: ___________________________________________________
AMOUNT DUE: __________________________
Account #: ________________________________
Charge Interest: No q Yes q If yes, specify rate: _____
Date of Invoice: ___________________________________________________
Date of Last Payment: _____________________________________________
MM/DD/YYYY
MM/DD/YYYY
Other pertinent details: ___________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Upon submission of the above account(s) for Debt Collection Services we understand and agree that we are obliged to immediately notify Eastern Credit Management Services of all payments received from
debtor, credits issued, returned goods or complaints and/or any agreements concluded with the debtor, relating to the claim. We hereby authorize Eastern Credit Management Services to proceed with the
collection of the account(s) which we certify as being legally owing and unpaid as stated above. We agree to pay commission on all monies recovered, credits issued and/or the value of any returned goods.
Please provide us with as much information as possible at the time of placement
560 Main Street, Suite 310, Saint John, NB E2K 1J5 Canada
for each account including a copy of the invoice and/or statement and any other
Phone/Téléphone: 506-634-8787 • Fax/Télécopieur: 506-634-0565
pertinent documentation. Mail, fax or email to:
Toll Free/Sans Frais: 1-800-561-4151 • •
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