On Broadway Collection Services
P.O. Box 87
Logansport, IN 46947
Phone: 800/488-1126
FAX 574/732-5115

ACCOUNT PLACEMENT FORM

Your Company Information:

Company Name: 
Address:
City: State: Zip:
Authorized by:
Telephone:

 

Debtor Information:

Company Name:
Fed ID #/SS#:
Contact Name:
Street Address 1:
Street Address 2:
City/State/Zip:
Telephone # (primary):
Telephone # (secondary):
Fax #:
Client Reference #:
Last Payment Date:
Amount Due:
Signed guarantee of payment? yes no

Submitting this information to our office authorizes On Braodway Collection Services to initiate collection proceedings on Clients behalf. Client agrees to be liable for the contingent fee on any payments made by debtor to On Braodway Collection Services or directly to Client, or on any accounts withdrawn by Client pending collections. Client authorizes On Broadway Collection Services to receive, endorse and deposit into On Broadway's trust account, any and all checks issued in Client's name. On Broadway will remit funds to Client after deductions of its fees.