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Placement for Collections
Placement for Free 10 Day Demand
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Please fill out your Company's information below:


Your Company Name	_________________________
Address:	_________________________
City:	_________________________
State/Prov:	_________________________
Country:	_________________________
Zip Code:	_________________________
Phone:	_________________________
Fax:	_________________________
E-mail:	_________________________

Please fill out Debtor's information below:


Debtor Company Name	_________________________
Address:	_________________________
City:	_________________________
State/Prov:	_________________________
Country:	_________________________
Zip Code:	_________________________
Phone:	_________________________
Fax:	_________________________
E-mail:	_________________________
Contact Name:	_________________________
Amount Owed:	_________________________
Date of Last Sale:	_________________________

Additional information that may be helpful (such as, what products were sold? What services were rendered?):___________________________________
____________________________________________

"Please print page, fill out and fax to: (302)351-6250"

Tanner & McKinley, Inc.
5609 N. Dupont Parkway
Suite #12
Smyrna DE 19977

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