Account Placement Form - LienMaster®

Creditor Information
Your Company's Name / D.B.A*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Debtor Information
Your Reference Number
Debtor's Corporate Name / D.B.A*
Debtor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Debtor's Phone*
Debtor's Email
Debtor's Fax
Amount Due*
USD/CAD
Date Debt Became Due
MM slash DD slash YYYY
Name of Contact
First Last
Debtor's Bank Information
Name of Debtor's Bank
Account Number
Address of Debtor's Bank
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Comments / Special Instructions
Miscellaneous
Please check the following boxes that apply:
- Statement / Invoices
- Credit Report
- Contract / Purchase Order
- Notes
- Correspondence
- NSF Check
- Guarantees
- Other
Submitted By*

By submitting this form, you are authorizing MCC / LienMaster to proceed with immediate collection.
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Accepted file types: jpg, pdf, doc, png, jpeg, Max. file size: 50 MB, Max. files: 10.
Name
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Creditor Information