Placement Form

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Client Information

*Company Name

Contact Full Name

Address

City

State (use "other" for out of USA)

Zip

Country

Phone 1

Phone 2

Email

FAX

BCC Salesperson

Client Number


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 in U.S. Dollars


Exchange Rate at Time of Transaction

Balance Due in Foreign Currency

*Date of Last Transaction

Documentation to Follow by:
Mail Fax Attachment
Copies only please. No originals.

 
Description:
 

Documentation & Attachments Include:
Invoice(s)
Credit Application
Itemized Statement
Original Contract
Notes or Drafts
COD NSF Check
Open Account NSF Check

Additional Information



*Verification Code



* BCC terms are acceptable










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