Debt Control Agency - We collect when others can't

Consumer Placement Online

Client Information


*Company name:

*Address:

Postal Code:

Fax:

*City:

*Province:

Telephone:

*Email:

*To enure the privacy and protection of your information, please make sure to type in your own correct email address in the email field above.

Debtor Information


Account Number:

*Debtor's SIN number

*Address

*Province:

Debtor's Homephone 1

Debtor's Homephone 3

Original Amount Due

Interest Amount Due

Do you have a signed Contract?
Yes No

Additional Information:

Name of Account:

Spouse's Name

*City

Postal Code

Debtor's Homephone 2

Debtor's Work phone 1

Current Amount Due

Total Amount Due

Debtor History:
Mail Returned
Phone Disconnected
Disputed
Check Returned
Inability to pay
Other

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