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To commence the debt collection procedure, simply the complete the form below.

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Instructions to Prime Collections: Please undertake collection action against the Debtor specified on this form for the debt described:

* Your Name:

* Work Phone:

Work Fax:

Mobile Phone:

* Email:

* Your Company or Business Name:

* ABN / ACN

Your Account or Reference Number:

* Trading Address:

Include State and Postcode

* Name of Debtor:

* Debtor ABN:

* Debtor Trading Address:

Including State and Postcode

* Debtor Phone:

Debtor Fax:

Debtor Mobile:

* Jobsite Address:

Or relevant address

* Date of Debt:

Day1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MonthJanuary February March April May June July August September October November December Year2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

* Amount of Debt:

* Type of Debt:

Dishonoured Cheque Services Goods Sold Other

Collection Costs:

Other Costs:

* Total To Be Recovered:

* The Debtor is Trading as:

Individual Business Company Not Known

* Name Registered:

Yes

No

Don't know

* Do You Have...

Purchase Order/s, Signed Work Dockets, Directors Guarantee, Signed Quotations or other? Please specify...

* Commence with:

Prime Collections Letter of Demand Solicitors Letter of Demand Legal Proceedings Field Call Need Advice Please

By clicking 'Lodge Debt', you (The Client) accept that action will be undertaken by Prime Collections on the basis of these Terms and Conditions.