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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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