NACM Business Credit Services Online Collection Placement Form

Debtor Name*: Contact Person*: Street address: Address (cont.): City: State/Province: Zip/Postal code: Telephone*: Fax: E-mail/Web address: $ Amount Due*: Your Customer or Account Number*: Date of Last Payment: Date of Most Recent Unpaid Invoice: Additional Amounts (interest, fees, etc.): Facts:

Please fax copies of the following information (if available): Credit Application, Personal Guarantee, Invoices, Bills of Lading, Proof of Delivery, Time Sheets, Copies of any Checks (front & back), any other pertinent information you feel investigators may want to know. Fax the information that accompanies this placement form to: (281) 228-6196

Acting as our agent, NACM is directed and authorized to pursue collection procedures necessary to enhance the successful collection thereof. It is understood that our authorization is necessary for an account to be forwarded to an attorney.

IT IS UNDERSTOOD THAT WE MAY WITHDRAW ANY ACCOUNT AT ANY TIME AFTER PLACEMENT WITH NACM, BUT WILL BE LIABLE FOR FULL COLLECTION FEES. We understand that we will be responsible for half the agreed fee for accounts that are discovered to have been paid prior, misapplied, credited, returned, billed in error or disputed. We agree that NACM has the right to endorse checks or other negotiable instruments received in payment. We also agree that NACM has the right to offset any outstanding fee. We are responsible to notify NACM promptly of any payment received directly by us on accounts placed with NACM. NACM will be entitled to normal fees on these direct payments. As our agent, NACM, from time to time, may accept settlement of an account only with our approval.

We understand that, once an account is assigned to NACM Business Credit Services, our employees should no longer actually work the account and should refer all callers to NACM Business Credit Services. We understand that NACM Business Credit Services will be paid their collection fee on all payments made after assignment. When a debtor petitions for bankruptcy, NACM will notify us and close the file. We are required to notify NACM immediately upon receipt of all petitions of bankruptcy. We understand that we will advance all court costs and attorney suit fees when necessary. Unless otherwise expressly agreed to by NACM, fees for collection will be based on the current published rate schedule.

Client Information
(if you are a returning client, you need only complete the Name, Company and Telephone fields below.)
Your Name*: Your Company*: Street address: Address (cont.): City: State/Province: Zip/Postal code: Telephone*: Fax: E-mail/Web address: Your Member Number**: Referred to NACM by: Must be filled out to qualify for % discount promo NACM Business Credit Services reports to all major commercial credit reporting agencies. I do I do not wish to have this placement reported Enter Promotional Code Here: By selecting the submit button, I indicate that I have read and agree to all term and stipulations on this page, and that I have the authority to bind my company. * Required field, ** Membership entitles you to discounts