Commercial icon  Load Commercial Debt

Fields marked * are mandatory fields

You can download this form here and email it to admin@cia.nz if you have trouble with this online form.
YOUR DETAILS

Company*:  

Trading As:

Contact Person*:

Address*:

Phone Number*:

Email*:

Phone Number:

Bank Number*:

 -  -  -   (For debtor payments to be paid into)

Your Reference:
       
DEBTOR DETAILS    

Company Name*:

 Email:

Trading as:

 Website:

Address:

Contact Person*:

 Phone Number 1:

Contact Persons Position:

 Phone Number 2  

Any other information that may be of help with collecting the debt i.e debtor's relatives contact details:

Upload a photo of this debtor:   

 

DEBT DETAILS

Amount Owing $*:                                                  

Invoice Number(s):                     

Date Incurred/Invoice Date:      (Enter in as XX/XX/XXXX format)

Please provide a brief explanation of the reason for this debt/dispute*:

Do your terms of trade have a debt collection clause*:  

Upload Invoice(s):                     

Upload Other Docs:                 

If you have additional photo's, documents, Court orders etc, please email them directly to us at admin@cia.nz 

 

  Click here to view Pricing Options

I have read and understood CIA Debt Recovery Limited's terms and conditions*

By accepting these terms, you agree to authorise CIA Debt Recovery Ltd to act as your agent in the above matters and agree to make payment of all charges and costs in accordance with the current terms and conditions.

You agree to not proceed to legal action, nor take independent action by another means through an agency or, on your own accord, against this debtor without first consulting CIA Debt Recovery Ltd. 

If you do take independent action or/and if any monies are paid to you or your agent, by the debtor, CIA Debt Recovery Ltd will invoice you for the full commission that relates to the option you have chosen above and any subsequent enforcement costs.

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