Receivable Management Corporation

Placement Authorization Form

DEBTOR

NAME:


ACCOUNT #:

ADDRESS:

CITY/STATE/ZIP:

PHONE: BUSINESS


PHONE: HOME

FAX:

CONTACT:

EMAIL:

CREDITOR

NAME:

ADDRESS:

CITY/STATE/ZIP:

PHONE:

FAX:

EMAIL:


CONTACT
:

 AMOUNT DUE:

Attached is an itemized Statement of Account. We hereby authorize RMC to proceed with collection. RMC is hereby authorized to endorse and negotiate for collection in our name, and on our behalf, remittances received on this account.

Information available from your credit and collection files is appreciated.

1. Do you have a personal guarantee:



Debtor Social Security Number:



2.Your experience with debtor:

SUBMITTED BY:


Upload an additional file here: (Maximum of 10MB)





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