Account Placement

CLIENT INFORMATION
Client Contact Name:
E-mail Address:
Existing Client Number:
Company Name:
Address 1:		Address 2:
City:
State/Country/Region:		Zip:
Phone:		Fax:
DEBTOR INFORMATION
Company-Individual Name:
Type of Business:
Debtor Account Number:
Address 1:		Address 2:
City:
State/Country/Region:		Zip:
Phone:		Fax:
Person(s) to contact:		Cont.
Amount Owed:		in
Last Sale Date:	,
Last Payment Date:	,
Other Helpful Debtor Information:

Hours of Operation:
24 Hours a Day, 7 Days a Week Contact Available

	U. S. Impact, Inc. 775 Asbury Drive Mandeville, La 70471-1843	E-mail: US Impact, Inc. Phone: 985.674.5350 Fax: 985.674.5386
	Toll-Free: 888.354.5350