Name

Company

Phone Number

E-Mail Address

Physical Address

City, State, Zip

Type of Business

Select One... Dental Medical Utility Hotel/Hospitality Grocery Real Estate Professional Veterinary Schools Other

If "other", please indicate below:

Are you interested in account receivables assistance?

Yes No

Do you currently work with a third party agency?

Yes No

How frequently do you have delinquent accounts?

If you could change one thing about your current agency, what would it be?

Select One... Recovery Rate Customer Service Reporting

If "other", please indicate below:

Are you interested in check recovery service?

Yes No

How often do you receive dishonored checks?

Do you currently accept credit cards?

Yes No

Remarks