Place an Account for Collection

If you have trouble viewing or sending this form click here for a Word Document which you can download and fax to us on 0292647343

You must be an existing client to place an account, if you are not an existing client and would like to join click here
Note: Once this form is submitted Commission is payable upon the account being settled.

Fields with an Asterix* must be filled in, the form will not submit if these fields are left blank.

YOUR COMPANY *
YOUR REFERENCE NO.
YOUR NAME *
YOUR PHONE NUMBER including area code *
YOUR EMAIL ADDRESS *
DEBTOR'S NAME *
DEBTOR'S ADDRESS *
DEBTOR'S SUBURB *
DEBTOR'S STATE *
DEBTOR'S POSTCODE
DEBTOR'S PHONE NUMBER
DEBTOR'S MOBILE
DEBTOR'S CONTACT NAME
DEBTOR'S ABN
DEBTOR IS A : Company Business Name Individual
DEBT AMOUNT $ *
CURRENCY *
DATE DEBT INCURRED: From *
DATE DEBT INCURRED: To
CAUSE OF ACTION
ACTION TO BE TAKEN BY FMC (Please select Required Action) *
DOES YOUR CUSTOMER CONTRACT ALLOW THE RECOVERY OF COLLECTION EXPENSES? Yes (Our commission will be added to the original debt value) No
IF YES, DATE OF CONTRACT
DOES YOUR CONTRACT ALLOW FOR INTEREST ON OVERDUE ACCOUNTS? Yes No
IF YES, WHAT IS THE % INTEREST RATE PER ANNUM?
IF YOUR CONTRACT DOES ALLOW FOR INTEREST HAVE YOU INCLUDED INTEREST IN THE DEBT AMOUNT ABOVE? No (FMC will add interest to the Debt Amount) Yes (Interest will not be added to the Debt Amount)
DO YOU HOLD A PERSONAL GUARANTEE? YES (Please Fax/email a copy to us) NO
IF YOUR DEBTOR IS AN INDIVIDUAL, ARE WE TO CONDUCT A BANKRUPTCY SEARCH? (Cost $33) YES NO
ANY OTHER RELEVANT INFORMATION
DO YOU AGREE TO FMC's TERMS AND CONDITIONS IN PLACING THIS ACCOUNT? * YES NO
Verification: