TWENTY–FIRST CENTURY ASSOCIATESPartnership In Collection Services

266 Summit Avenue • Hackensack, NJ 07601

Tel. 201 678-1144 Fax. 201 678-9088
Back to Main Page

PLACEMENT  FORM

IMMEDIATE COLLECTION     Check for 10-DAY FREE DEMAND SERVICE

DEBTOR
DATE                     AMOUNT    
 
TRADE STYLE DBA
DEBTOR FAX
ADDRESS
CITY                                     STATE        ZIP
     
BUSINESS PHONE NUMBER
HOME  PHONE NUMBER
PRINCIPAL OFFICER        TITLE
OTHER CONTACT            TITLE
BANK                          ADDRESS
ACCOUNT NUMBER

DEBTOR IS A:      CORPORATION   PARTNERSHIP PROPRIETOR INDIVIDUAL

DOCUMENTS (CHECK BELOW AND FORWARD BY MAIL)
  ITEMIZED STATEMENT CREDIT APPLICATION RETURNED CHECK(S)
  INVOICE COPIES CREDIT REPORTS COPY OF DEBTOR'S CHECK(S)
  PROOF OF DELIVERY PROMISSORY NOTE OR
OTHER INSTRUMENT
PERTINENT CORRESPONDENCE
  BANK OTHER

 

REMARKS


You hereby authorize Twenty-First Century Associates, to endorse in your company's name, and to negotiate or to deposit in any bank account of Twenty-First Century Associates. any and all checks, notes, drafts, bills or exchange or other orders for the payment of money payable or endorsed to you which come into Twenty-First Century Associates. possession by virtue of its acting as your collection agent, and to remit the proceeds to you, less any fees which may be due whether or not such fees relate to the claim for which the funds were received.   Twenty-First Century Associates. may use any funds collected to offset any open fees due Twenty-First Century Associates. for any account submitted to Twenty-First Century Associates. for collection.

SIMPLIFIED COMMERCIAL RATES

Where necessary, Twenty-First Century Associates is authorized to forward this account to a bonded commercial attorney.

CREDITOR

TELEPHONE NUMBER
REQUIRED
ADDRESS
CITY                                                STATE     ZIP
     
BY                                               TITLE
 
YOUR E-MAIL ADDRESS   REQUIRED
Twenty-First Century Associates will e-mail an acknowledgement.
   

Copyright 2003 Twenty-First Century Associates ALL RIGHTS RESERVED