Advanced Collection Services Ltd.

Consumer Account Application Form

Any account listed not under arrangement of payment or contact may be withdrawn on written request after 90 days.

ACCOUNTS SERVICED DAY RECEIVED

Additional Information
Debtor Information
Debtors Full Name
Amount Owing
Last Known Address		Postal/Zip code
City		Province or State
Country	Phone Number		Date Of Birth
S.I.N.		Drivers License Number
Employer		Employer Phone
Relatives/References
Date of last Payment	Interest Rate		Interest Effective Date

Creditor Information
Client Number
If you already have a client number your company name, contact person and telephone number will be sufficient.

Name

Contact Person

Address

City

Province or State

Postal or Zip code

Country

Phone Number

Fax

E-mail

Creditor Information		Client Number If you already have a client number your company name, contact person and telephone number will be sufficient.
Name
Contact Person
Address
City
Province or State		Postal or Zip code
Country		Phone Number
Fax		E-mail

Advanced Collection Services Ltd.

Consumer Account Application Form

Debtor Information

Creditor Information

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