Sample agreement
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Company Profile
(click on any item if you need an explanation)
Merchant
Name:
Tax ID:
Address:
City:
State:
Zip Code:
Owner/Contact Person:
Contact Phone:
Fax:
Email Address:
Estimated # of Checks/Month:
# of Locations and POS (point of service) locations requiring disclosure stickers:
Payment Method Desired:
Paper check
Electronic deposit
Bank Name:
Bank Routing Number:
Leave blank
unless you want your money returned electronically
.
Client Account Number:
Leave blank
unless you want your money returned electronically
.
Check Collections Options:
Phase I
Phase I & II
Phase II Selection:
Automatic
Selective
Report to National Credit Bureaus:
YES
NO
Legal Action to Include judgment/garnishment:
YES
NO
Filing with local district attorney and/or law enforcement:
YES
NO
Requested length of time that items are to be in Phase II Collections:
6 Months
12 Months
18 Months
Return Items Mailed to Client Monthly?
YES
NO
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