A
ffiliated
C
ollection
S
ervice
P.O. Box 3596, Clearwater, FL 33767
of Florida, Inc.
Phone 727-466-0772 Fax 727-466-0769
NEW CLIENT
Information Sheet
Client # _____________ Date Placed: __________________ Commission rate: ________%
Business Name:
Address:
City:
State:
Zip:
Phone #:
Fax #:
Contact Person:
Email Address:
This agreement is to authorize Affiliated Collection Service, to act as
agent in collecting delinquent accounts. This agreement remains in
effect until it is re-negotiated or canceled by mutual consent.
Additional Notes:
1) Data received electronically, or by mail.
2) Do not deal with customer/patient after referral; you may be charged with harassment.
Refer them directly to our office.
3) Report payments made to you, the day you receive them; for credit reporting purposes.
Comments
Client Signature: _______________________________________ Date: _________________
Title: _______________________________________
Thank you for your business
or