| CLIENT INFORMATION
NAME: _________________________________________________________________
PHONE: ________________________________________________________________
FAX: __________________________________________________________________
AUTHORIZED BY: _______________________________________________________
AUTHORIZED SIGNATURE: _______________________________________________
DATE: _________________________________________________________________
DEBTOR INFORMATION
DEBTOR NAME: _________________________________________________________
ADDRESS: _____________________________________________________________
PHONE # : _____________________________________________________________
POE # : ________________________________________________________________
FAX # : ________________________________________________________________
CLIENT REF/ACCT #: ____________________________________________________
OUTSTANDING BALANCE: ________________________________________________
Please forward invoices, statements and credit applications if possible.
Thanking you in advance, Eric White, President Maritime Accounts Receivable
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