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DAL Placement Form
More Placement Options
Fields marked with * are required.
DEBTOR INFORMATION
Customer #:
Company Name:
Company Name 2:
Contact Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Debtor is a:
Business Phone:
Ext.:
Home Phone:
Cell Phone:
Fax Number:
Email Address:
Web Address:
Date of Last Payment:
Date of Oldest Invoice: Help Icon
*Amount Due:
CREDITOR INFORMATION
DAL Client ID:
Creditor:
Alias:
Address:
City:
State:
Zip Code:
Web Address:
Phone:
Ext.:
Fax:
Cell Phone:
Contact:
*Email:
DOCUMENTATION: (check all that apply)
Please note that documentation is required for processing to begin. Documentation provided by you today avoids future requests that can delay our collection efforts.






I will be forwarding documentation by:


(10 MB (10,000 KB) max size of all files)
EXPERIENCE: (check all that apply)



Comments or Special Handling Instructions:
By hitting Submit Account for Collection, I also agree to the
DAL Conditions of Service.