Commercial Placement Client Information Company Name Contact Address First Name Company Name Address City State—Please choose an option—select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWyomingOther Zip Telephone Fax Email Commercial Placement Debtor Information Business Structure—Please choose an option—please choose oneCorporationPartnershipSole ProprietershipIndividual Company Name Owner Company Contact Address City State—Please choose an option—select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWyomingOther Zip Telephone Fax Type of Claim—Please choose an option—collectionsServicesMerchandisePromissory NoteNSF Check —Please choose an option—subrogationAutomobileFraudContractOther Debtor HistoryMail ReturnedPhone DisconnectedDisputedCheck ReturnedInability to PayOther Additional Information Guarantor Information Do you have a personal guarantor ?YesNo Guarantor Name Guarantor Social Security Number Address City State—Please choose an option—select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWyomingOther Zip Telephone Original Amount Due Current Amount Due Account Number Date of Service Date of Last Activity Do you have a signed contract ?YesNo Additional Information Please Read Before Submitting:In submitting files for placement, the named client authorizes Your Collection Solution, Inc. to act as it's agent with respect to collections. Furthermore, client authorizes Your Collection Solution, Inc. to deposit all checks received into Your Collection Solution, Inc. Trust account. Your Collection Solution, Inc. will remit funds to client after deducting the agreed contingency fee. Disbursements will be paid biweekly when said monies have cleared our bank. In addition, client agrees to remit to Your Collection Solution, Inc. any monies received which were paid directly from the debtor less the agreed contingency fee. Captcha