Commercial / Industrial Accounts


 (* indicates required field)

Please Start (select service to start):
*Client Name:  
*Client Number:  
*E-Mail Address:
Debtor Information:
*Business Name:  
Debtor Acct #:
*Business is a Corporation Individual DBA Partnership
*Physical Address:
*City *State Zip
Mailing Address:
City State Zip
Phone #: FAX #: Other Phone #:
Is Mail Returned?:Yes
Bank: Acct No.:
*Date Last Service: Interest Through:Date Last Payment:
*Principal: Interest: Service Charge:
Other Information:
The above account is hereby assigned to Cal Coast Credit Service, Inc., (referred to herein as CCCS) for collection and is bound by the existing relationships terms and conditions. A pre-arranged fee or charge is to be paid to CCCS, upon any claim listed, collected, settled with approval, paid directly or withdrawn during the process of collection. It is our responsibility to notify CCCS immediately of any payment received by us, status change or cancellation request to avoid unnecessary effort and additional costs.
Name & Title of Person Placing / Signing Orders: (must be authorized to assign account)