DAL, Inc.

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DAL PPA - Client Services

Placement Form

DEBTOR INFORMATION

Debtor:
Customer #:
Address:
Address2:
City:
State:
Zip:
Business Phone:
Home Phone:
Fax Phone:
Cell Phone:
E-Mail:
Web Address:
Contact Name:
Date of Last Payment:
Date of Oldest Invoice:
*Amount Due:

Experience:

Debtor is a:

Documentation:
Please note that documentation is required for processing to begin.

I will be forwarding documentation by:

dal@dalcollects.com

Remember: Documentation provided by you today, avoids future requests which can delay our collection efforts.

Comments and Special Instructions:

WAIVE THE 10 DAY FREE DEMAND

CREDITOR INFORMATION
* required field

Creditor:
Contact:
Address:
City:
State:
Zip:
Phone:
Fax:
Cell Phone
*E-Mail:
Web Address:
Attach file:

By hitting "Submit", you acknowledge that you have read and agree to DAL's Conditions of Service for claim placement. If you would like to view the "Conditions of Service", Click Here.

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DAL, Inc.
300 E. Madison Avenue
Clifton Heights, PA 19018
TEL: 1.800.355.9999
FAX: 1.888.220.9990
Email: dal@dalcollects.com

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