Placement Form

	Client Information:	*Required Field
(All commissions are strictly contingent upon collection)

Company Name*

Contact Name

Phone 1

E-mail

Fax

Debtor Information:

Name of Account*

Responsible Person

Address*

City*

State*(use "Other" for out of USA) Zip*

Phone 1

Phone 2

E-mail

Account #

Balance Due* $

Date of Last Invoice*

Additional Information:

Please send a copy of this form to my e-mail account.