Debt Control Agency - We collect when others can't

Consumer Placement Online

Client Information

*Company name:


Postal Code:






*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



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


Postal Code

Debtor's Homephone 2

Debtor's Work phone 1

Current Amount Due

Total Amount Due

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

footer image
Copyright © Debt Control Agency 2006-2010. All rights reserved.