PLACE AN ACCOUNT FOR COLLECTION

 

Are you a client of MSR? Yes   No

Client number
Current MSR Clients may click here to skip company information
Please complete the following:.

Company  name
Contact name
Street address
Address (cont.)
City
State or Province
Postal  code
 Phone
FAX
E-mail
How did you find us? 
Details:
 

Debtor Information

Name: Contact Name:  

Address: City:  
State:Zip: 
Home Phone:: Social Security Number:  

Phone: Fax:

Second Placement: Yes  No

Date of debt: Reference Number:

Please indicate if you have a contract or credit application allowing for additional costs such as interest and collection fees. If so what amount can be added to the principal due.
Principal
Amount Due: 		Interest and/or collection fees:

Services Rendered:

Please send copies of the following: 
  • Statement/ Invoices
  • Contracts
  • Credit Applications
  • Bank Information
  • Personal Guarantee
  • Bad Checks
  • Judgments

You may fax them to 954 783 7232

 

How many accounts will you be placing with us today?  

 Additional accounts may be submitted upon completing and submitting this form.

What is the "total dollar amount" of today's placements?  
How would you like us to handle your accounts?
Maximum Effort
Normal Efforts
Go easy - We would like to keep them as a client if possible.
Email address to contact you: