July 25, 2008
www.garcollect.com
CREDITOR INFORMATION
*
Required field!
Creditor/Company Name:
*
Contact Name:
*
Title:
*
Address:
*
Addres 2:
City:
*
State:
*
Zip Code:
*
Phone #:
*
Fax #:
Email:
*
URL:
DEBTOR INFORMATION
Debtor/Company Name:
*
Contact Name:
Title:
Address:
Addres 2:
City:
State:
Zip Code:
Home Phone #:
Work Phone #:
Fax #:
Email:
Debtors Bank Name:
Account Number:
Bank Address:
Bank Address 2:
City:
State:
Zip Code:
Corporate Officers:
ACCOUNT INFORMATION
Amount to be Collected:
*
Your Account Number:
Last date of service/payment:
Debtor Invoice Number:
Debtor History:
Phone Disconnected
No Response
Checked Returned
Disputed
Mail Returned
Claims Inability to pay
Other (please specify below)
Explain any Disputes:
Additional Information:
Top
500 Grove St., Suite 300
Haddon Heights, NJ 08035
Phone 856-833-9055
Fax 856-833-9450
July 25, 2008
Haddon Heights, NJ 08035 Phone 856-833-9055 Fax 856-833-9450