Printing Industry Credit Bureau / PCMA

PROFESSIONAL CREDIT MANAGEMENT ASSOCIATES ACCOUNT PLACEMENT FORM

CLIENT INFORMATION

*COMPANY NAME:
Required.

STREET ADDRESS:

CITY:

STATE:

ZIP:

*CONTACT PERSON:
Required.

*PHONE: (e.g. 000-000-0000)
Required.Invalid format.

FAX:

*EMAIL:
Required.Invalid format.

DEBTOR INFORMATION

DEBTOR COMPANY NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP:

CONTACT PERSON:

PHONE:

MOBILE PHONE:

FAX:

CLAIMED AMOUNT:
$

DATE DEBT WAS INCURRED:

I WILL PROVIDE THE FOLLOWING IN SUPPORT OF OUR CLAIM.
(PLEASE INDICATE ONLY THOSE ITEMS THAT APPLY TO THIS CASE):

PLEASE INDICATE THE STATEMENT(S) THAT APPLY TO THIS CASE:

	IS YOUR DEBTOR OUT OF BUSINESS?	PLEASE PROVIDE DETAILS BELOW ABOUT THE DISPUTED CLAIM:
	IS MAIL BEING RETURNED?
	IS YOUR CLAIM DISPUTED?

THIS CLAIM IS SUBMITTED BY:

NAME:

TITLE:

TODAY'S DATE:

BY SUBMITTING THIS CLAIM, YOU AGREE TO THE STATED TERMS AND CONDITIONS
PLEASE READ TERMS AND CONDITIONS BEFORE SUBMIT CLAIM