Place Account


Client Information (Creditor)

Debtor Information

Personal Guarantee (PG)    Yes, attach a copy No
Still in Business    Yes No
Credit Application/PG
Additional Back-Up

By submitting an account for collections using this form you hereby authorize
RAB, Inc. to begin IMMEDIATE collection activities. Please report all
payments promptly. Should the debtor attempt to contact you directly you
hereby agree NOT to communicate with the debtor and will refer them back to
RAB, Inc. Cancelling/Withdrawing an account submitted for collections will
result in full commission to be due.


Thank You For Your Continued Trust.


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