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      Your Information :
    Required Fields *  
      Your Name: *
      E-Mail: *
      Company Name/ID #: *
      Company Address: *
      Company City: *
      State: *
      Zip: *
      Work Phone: - - *
      Fax: - -
     Account Information:
      Account type: Pre-Collect Collection Billing *
      Amount Due to You: * Interest Rate: *
      Account No.
      Last Date of Service:
     Debtor's Information:
      Name: *
      Address: *
      City: *
      State: *
      Zip: *
      Home Phone: - -
      Work Phone: - -
      SSN: - -
      Date of Birth:
      Employer:
      Employer Phone: - -
      Spouse's Name:
      Spouse's Employer:
     Additional Comments (i.e. breakdown of charges, info, etc.) :

    THE ACCOUNT LISTED ABOVE IS HEREBY PLACED FOR COLLECTION AND IS SUBJECT TO OUR REGULAR RATES AND CONDITIONS.


    Have questions?
    info@urs-inc.com
     




    Try our online
    placement form.

    A convenient way to place accounts for collection.

    Your IP Address is: 38.107.179.218

    United Resource Systems, Inc. 10075 W. Colfax Avenue Lakewood. CO 80215
    303.205.0152   Fax 303.205.0153  Toll Free 1.800.441.7364

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