Please fill out the online form below. Fields marked with an asterisk * are required. Alternately you can download a copy of the form below.
Download debt recovery form. Download account application form.
Client Status
First Name
Last Name
Company Name (if applicable)
Trading Name
Postal Address
Phone
Mobile
Fax
Email
Bank Account Name as appears with your bank
Bank Account #
Phone (private)
Phone (work)
Date of Birth
Last Known Postal Address
Last Known Physical Address
Type of Entity
Joint Debtors' Names)
Personal Guarantee Held
Agreement to Pay Costs
**Costs can only be added to the debt if the customer was advised at the time of incurring the debt that should default occur, costs would be added to cover collection costs. To enforce this, they must have completed a credit application form or a hire purchase contract. Alternatively, you must have a sign prominently displayed in your reception area and they must have been made aware of this.
Amount of Debt
Date Debt Incurred
Client Reference
Description
Terms and Conditions