Call: 877-888-5657 Ext 102
Kevin@alazassoc.com
Debt Placement Form *Required information
Debtor Information:
Company Name*:Company Address*: City/State/Zip*:Country:
Type of Business*:
Individual Responsible:
Amount Owed*:
Telephone*:
Fax:
Email Address:
Date of Sale*:
Date of Last Payment:
Your Account #
_________________________
Your Company Information:
Company Name*:
Address*:
City/State/Zip*:
Type of Business:
Indvidual Responsible*:
Telephone*:
Fax*:
Email Address:
Comments:
Referred by*:
