Existing Client Placement Form

Please enter your placement information below:

Client Name:

Client Number:

Debtor Name:

Debtor Address:

Debtor City:

Debtor State:

Debtor Zip:

Debtor Phone 1:

Debtor Phone 2:

Debtor Phone 3:

Debtor Fax:

Debtor Email:

Debtor Contact:

Debtor Contact Title:

Amount Owed on Account:

Date of Last Unpaid Invoice:

Date of Oldest Unpaid Invoice:

Product/Service Provided:

Terms:

Comments or Additional Information:

By clicking the “I agree” button you agree to the following: This form authorizes Merritt, Landers & Martin to begin immediate collection action against the Debtor named above. Any and all payments remitted directly to you after the date entered above shall be deemed as having been collected by us, and shall incur the full applicable collection fee. If no collection is made, there will be absolutely no charge for our services. We also agree to pay client for any monies sent to us by the debtor within 21 days of receipt of payment. All payments made to Merritt, Landers & Martin LLC will be reported to client immediately. All collection activities will be undertaken in accordance with all state and federal collection laws.