IMMEDIATE PLACEMENT FORM

All commissions are strictly contingent upon collection.

Client Information:

*Company Name      
 Contact Name      
 Address           
 City              
 State             (use "other" for out of USA)
 Zip               
 Country           
 Phone 1           
 Phone 2           
 Email             
 FAX              
 Salesperson      Vince321
Debtor Information:

*Name of Account                  
 Responsible Owner/Officer/Party  
 
*Address          
*City             
*State            (use "other" for out of USA)
*Zip              
 Country          
 Phone 1          
 Phone 2          
 Email            
 Account #        
*Balance Due      
    Exchange Rate at Time of Transaction  
                            U.S. Dollars  
*Date of Last Transaction
Documentation to Follow by Mail or Fax
(Copies only please. No originals): 
Invoice(s)               
Credit Application       
Itemized Statement       
Original Contract        
Notes or Drafts          
COD NSF Check            
Open Account NSF Check
Additional Information:

By clicking the submit button I agree to a 45% rate.