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New Client Acceptance
Form
or Rate Change 
"THIS FORM MUST
BE COMPLETELY FILLED OUT FOR EACH NEW CLIENT"
"SO THERE IS NO MISUNDERSTANDING"
DATE: __________________________
CLIENT'S COMPLETE NAME: __________________________________________________________
ASSIGNED CLIENT NUMBER: __________________________________________________________
MAILING ADDRESS: _________________________________________________________________
PHONE NUMBER: ____________________________________________________________________
FAX NUMBER: ______________________________________________________________________
CONTACT PERSON IN CLIENT'S OFFICE: _______________________________________________
COLLECTION FEE SCHEDULE
| [ ] |
HEALTH CARE |
35% UNDER 4 MONTHS*/40%
OVER 4 MONTHS
Fee Contingent Upon Collection |
_____
Client Initial |
| [ ] |
UTILITY |
40% LESS THAN 1
YEAR
Fee Contingent Upon Collection |
_____
Client Initial |
| [ ] |
RETAIL |
40% LESS THAN 1
YEAR
Fee Contingent Upon Collection |
_____
Client Initial |
| [ ] |
RENTAL PROPERTY |
50% FEE
Fee Contingent Upon Collection |
_____
Client Initial |
| [ ] |
ACCOUNTS OVER 9
MONTHS OF AGE
SECOND PLACEMENT ACCOUNTS
ACCOUNTS REQUIRING LEGAL ACTION
ACCOUNTS UNDER $175.00
SKIP TRACED ACCOUNTS
FORWARDED ACCOUNTS
ALL NSF CHECKS |
50% FEE
Fee Contingent Upon Collection |
_____
Client Initial |
* FROM DATE OF LAST PAYMENT OR CHARGE
| Sales Representative Signature:
___________________________ |
Date: __________________ |
| Client Signature: _______________________________________ |
Date: __________________ |
| Approved By: _________________________________________ |
Date: __________________ |
| Data Processing Acceptance:
___________________________ |
Date: __________________ |
* * THANK YOU FOR CHOOSING EAU/CSD COLLECTIONS
* *
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