REQUEST TO LODGE A DEBT

Please complete the form below to authorise Creditcom to act on your behalf in the specified matters. Or alternatively, you can download and print our DEBT RECOVERY Pack here.

We hereby request Creditcom to act on our behalf, in accordance with the following details, to recover monies allegedly owing to us.

* Required fields begin with an asterisk *

DEBTOR DETAILS
* Company / Business / Entity Name:
* Contact Name:
* Position / Title:
* Postal Address:
* State:
* P/Code:
* Ph:
Fax:
Mob:
Email:
Website:
* Transaction Description:
Additional Comments:
* Date of Debt:
* Invoice #:
* Amount:
YOUR DETAILS
* Date:
* Registered Business or Company Name:
A.B.N.:
A.C.N.:
* Contact Name:
* Position / Title:
* Postal Address:
* State:
* P/Code:
* Ph:
Fax:
Mob:
* Email:
Website
Additional Details:
* I accept the Terms & Conditions of Debt Collection and agree to be bound by them unconditionally . I am the above mentioned authorised representative of the above mentioned Entity.