DAL Placement Form

Call: (800) 355-9999 | Email: dal@dalcollects.com

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:

Debtor Bus. Phone:

Ext.:

Debtor Home Phone:

Debtor Cell Phone:

Debtor Fax Number:

Debtor Email Address:

Debtor Web Address:

Date of Last Payment:

Date of Oldest Invoice:

*Amount Due:

CREDITOR INFORMATION

DAL Client ID:

Creditor:

Alias:

Address:

City:

State:

Zip Code:

Creditor Web Address:

Creditor Phone:

Ext.:

Creditor Fax:

Creditor Cell Phone:

Creditor Contact:

*Creditor 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.

Credit Application
Statements
Invoices
NSF Checks

Correspondence
Personal Guaranty
Contract
Other

I will be forwarding documentation by:

Fax: 610-623-1080
Mail:

DAL, Inc.

PO Box 162

Clifton Heights, PA 19018

Email:

dal@dalcollects.com

Attached to this Form

(50 MB (50,000 KB) max size of all files)

EXPERIENCE: (check all that apply)

Claims Inability to Pay
Broken Promises
Ignores All Demands

Disputed (explain below)
Other (explain below)

Comments or Special Handling Instructions (450 character limit):

By hitting Submit Account for Collection, I also agree to the
DAL Conditions of Service.