| Names of Debtor/Company: |
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| Known Aliases of debtor: |
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| Company Director(s) (If applicable): |
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| Your reference: |
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| Gender: |
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| Date of Birth: |
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| Debtor's email address: |
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| Debtor's Photo ID: |
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| Photo ID Version (if applicable): |
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Please itemise these details – Please attach a copy of your Invoice and any credit application forms you got the debtor/company to complete – please state below in "any helpful details" field if your terms and conditions allow for collection costs to be added to the debt.
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| Details |
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Amount (numbers only, no words) |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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| Subtotal: |
$ |
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| Less Bond: |
$ |
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| Less other credit/paid since Court order: |
$ |
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| Total to recover: |
$ |
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| Current home address of debtor: |
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| Suburb: |
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| Town / City |
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| Current home phone: |
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Company Name:
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| Work address /Registered office address: |
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| Suburb: |
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| Town/City: |
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| Occupation: |
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| Work Phone: |
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| Mobile Phone: |
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| Car Reg. No.: |
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| Any other helpful details: |
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| Description of debtor1 (e.g. 5’10” tall, tattoos, distinguishing features |
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Upload Photo:
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| OUR SPECIFIC INSTRUCTIONS |
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| Our Details |
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| Email Address: |
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| My Company/Name: |
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| Postal Address: |
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| Suburb: |
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| Town / City |
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| Post Code: |
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| Physical address: |
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| Suburb: |
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| Town / City |
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| Post Code: |
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| Contact person: |
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| Phone: |
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| Mobile Phone: |
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| Fax: |
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| Position: |
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| My bank account number for direct credit of any proceeds of recovery |
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| Billing Option: |
Fee schedules |
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I/We authorise The C.I.A. Debt Recovery Group Ltd to act as our agents in the above matters and agree to make payment of all charges and costs in accordance with The C.I.A. Debt Recovery Group Ltd current terms and conditions. I/We agree to not proceed to legal action, nor take independent action by any other means through agency or on my/our own accord, against this debtor without first notifying The C.I.A. Debt Recovery Group Ltd.
If I/we do take independent action, I/we know we will be liable and be invoiced for the whole commission that relates to the option I have chosen above and any subsequent enforcement costs. |
| We understand and agree to these terms |
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| Please attach any supporting documentation. Please note we will formally acknowledge your instructions, after assigning this debt a reference number, by email |
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Upload Files:
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