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Placement Form
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Note: An asterisk (*) marks required
information. |
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For your convenience, you may download a
PDF®
version of this form. This may by printed and duplicated, and, when completed, submitted via fax to: 706-219-1831. This may be easier when placing multiple claims. You may download
Adobe Acrobat® Reader® software (free), If you do not already have it.
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*Date |
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DEBTOR: |
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*Co:
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*Address 1: |
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*Address 2: |
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*City: |
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*State |
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*ZIP |
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Phone: |
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Email: |
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*Amount of debt: |
$ |
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CREDITOR: |
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*Co:
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*Address 1: |
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*Address 2: |
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*City: |
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*State |
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*ZIP |
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Phone: |
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Email: |
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In order to
expedite the efforts of The Rand Agency, Inc., dba Rand Associates, on
your behalf, any of the following information that is available from
your credit and collection files will be appreciated. At the very
least, a copy of a current itemized statement should be either faxed
to 706-219-1831 or emailed to
bshrand@alltel.net. |
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Name(s) & position(s)
of debtor’s responsible individual(s) |
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*Debtor’s business phone (w/ area
code) |
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Fax: |
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Responsible individual’s residence
phone: |
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Debtor’s banking connection: |
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Debtor’s business type: |
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Corporation
Partnership
Sole
owner |
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*Your experience with
debtor |
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Broken promises
NSF Checks
Dispute
Out of business
Ignores all demands |
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Enclosures:
to be faxed to 706-219-1831 or emailed to
bhsrand@alltel.net.
Be sure to reference Debtor, Amt. & Date of Submittal. |
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Statement
Invoice(s)
Correspondence
Guarantees
NSF
Checks
Credit
Report
Other |
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Any special
circumstances, information, or instructions: |
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By virtue
of the electronic submittal of this form, we agree to rates, terms and
conditions; and you are hereby authorized to endorse in the name of
the undersigned firm, and to negotiate or to deposit in any Rand bank
account, any and all checks, drafts, bills of exchange or other orders
for the payment of money payable or endorsed to the undersigned which
come into your possession by reason of your acting as Collecting Agent
for the undersigned and their firm. |
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*Submitted by:
(Person to whom we should send correspondence) |
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*Title |
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Before
submitting, please check this form carefully for possible errors,
especially in numbers. |
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Clear form to start over |
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Rand Assoc.
3256 Hwy. 255 South Cleveland, GA 30528 800-699-6910 |
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