Main Line 602-297-9200
Fax Line 866-867-1084
Toll Free 866-460-7898
333 E. Osborn Road,
Suite #370
Phoenix, Arizona 85012

FAX PLACEMENT FORM

Your Company Info    * required information

Client #

* Name:
 		* Your Name:
  

Sales #

Address: City:
State:

Zip:

* Phone: Fax:

Date:

* Your Email Address:

Debtor Information
* Debtor Company Name:
 

Your Reference #

* Address: * City:
* State:

Zip:

* Phone:
 Alt. Phone:
 Fax:
* Contact Name:

Date of Last Sale:

* Amount Due: Add-ons:

TOTAL:

Comments: 
 

BACKUP
* Personal Guarantee Yes No  * NSF Check Yes No  * Credit Application Yes No

I authorize AIP Solutions to initiate collection activity on the above account.
Signature:
 Print Name:
 Date:

Please fill in this form, print it and fax to 866-867-1084

FOR OFFICE USE ONLY
Assigned to Collector #:    Rate: %      Prime Yes No    PHIN Yes No

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