Agreement

Please submit your basic information below regarding your account to start the collection process.A Service Representative will get back to you for any additional information we may need.

Your Information:

Date:

Type of debit:

Your First Name:

Your Last Name:

Your Company:

Address:

City:

State:

Zip Code:

Phone:

Fax:

E-mail:

Outline of Products
or Services:

Debtor Information:

Debtor company:

Debtor name:

Debtor address:

City:

State:

Zip Code:

Debtor phone:

Fax:

E-mail:

Amount due:

Inv #/s
Date/s & Amt/s :

Additional Information:

Your Name:

By entering your name and clicking the above button you authorize Elite Premium Collections, Inc individually or as a company representative 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 collection activities will be undertaken in accordance with all state and federal collection laws.

De Oña Group | Elite Premium Collections Inc. Website.