COMMERCIAL LISTING FORM
Debtor Business Name:
Debtor is:    Corporation   Co-partnership   Individual
Address
2nd Address
City Zip -
Phone Number -- Bank Code
Owner's Name:
Last First Middle
2nd Owner (If more than one owner):
Last First Middle
Home Address
Home City Zip -
Home Phone Number -- E-Mail Address
Business:
Type of Business
Debtor Bank
Amount of Claim $
Date of Last Charge  
Last Payment $
Date of Last Payment
Claim:     Book Account Agreement/Note/Contact NSF Check Judgment
Additional Information:
We hereby assign to THE NATIONAL COLLECTION AGENCY, INC., the account listed above, subject to
your current commercial fee schedule. It is understood you will not forward or sue without our granting
permission. When permission to sue is granted we agree to advance all court costs. All sums collected in
addition to the amount listed as due shall be retained by you except court costs advanced by us, which will
be refunded only when the account is paid in full.
Creditor
Address
City Zip -
Phone Number -- Email Address




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