Client Information
*Company Name
Contact Full Name
Address
City
State (use "other" for out of USA)
Zip
Country
Phone 1
Phone 2
Email
FAX
BCC Salesperson
Client Number
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Debtor Information
*Name of Account
Responsible Owner/Officer/Party
*Address
*City
*State (use "other" for out of USA)
*Zip
Country
Phone 1
Phone 2
Email
Account #
*Balance Due in U.S. Dollars
Exchange Rate at Time of Transaction
Balance Due in Foreign Currency
*Date of Last Transaction
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Documentation & Attachments Include:
Invoice(s)
Credit Application
Itemized Statement
Original Contract
Notes or Drafts
COD NSF Check
Open Account NSF Check Additional Information
*
BCC terms are acceptable
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