National Credit Solutions

Contact Name/First & Last (required)

Job Title

Company Name

Company Address

Company City

Company State (required)

Company Zip

Phone Number (required)

Primary Email Address (required)

Fax

How did you hear about us?
 Online Search Radio Advertisement Newspaper Advertisement Billboard Referral Other

Are you looking to collect from
 A business An individual(s) Both a business and individual(s)

How many past-due accounts are you considering placing with NCS?

What is the average past-due balance of accounts?

Approximately how long, on average, have the debts been outstanding?
 A few weeks old Several months old 1-3 years old 3-6 years old 6 + years old

Has your paper been placed with an agency before?
 Yes No

If yes, please list any agencies

Do you have a budget for collections?
 Yes No

Describe your type of business

Have you been contacted by a Client Liaison?
 Yes No

Any additional comments or questions:

You will be contacted soon via telephone or by e-mail by a client liaison.

We thank you for your interest and look forward to doing business with you.