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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