Fast Track My Debt Instruction Form

Please complete as much detail as possible when completing this form. The more information you provide the more effective we can be and the less likely we will need to interrupt your day to seek more information. Thank you for your cooperation.

Your Details
Company/Business Name:	*
:
First Name:	*
Last Name:	*
ABN/ACN:
Business Address:
Postcode:
Is the street address your postal address?:
Postal Address:
Postcode:
Phone Number:	*
Mobile:
Email Address:	*
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Debtor Detail
Debtor's Full Legal Name:	*
ABN/ACN:
Contact Person:
Address:
Postcode:
Phone Number:
Fax Number:
Mobile:
Email Address:
Do you have more information about the Debtor:
Occupation:
Current Employer:
Previous Employer:
Known Assets:
Other:
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Debt Details
Debt Relates to:	*
Date of Debt:	*
Balance Owing:	*
Copy of Invoice:
Copy of Invoice:
Is Interest Recoverable:
Rate %:
Are collection costs recoverable?:
On what basis?:
State:	*
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Attempted Recovery Details
Is the debt disputed?:	*
	IMPORTANT: If you fail to disclose the existence of a dispute that you are aware of we will be entitled to compensation equal to the greater of $250 and 20% of the maximum commission that we could derive from collecting the debt in full (plus GST) - See clauses 5.5 of the Collection Service Agreement -Terms & Conditions (1 October 2015).
Please describe the nature of the dispute?:
Has there been any recent contact?:
On which date?:
What happened?:
Do you have any security for payment (eg Mortgage, charge, retention of title):
Please describe:
Is there a Guarantor?:
Name:
Address:
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Please take the following approach:
Please take the following approach:
	I accept and agree to be bound by the Collection Service Agreement -Terms & Conditions (1 October 2015) and wish to appoint Fast Track Debt Collection as my collection agent *
Name: (Please Note: By typing your name here this constitutes your signature):	*
Position: (Please Note: State Position if Signing on behalf of a business):	*

Fast Track My Debt Instruction Form

Please complete as much detail as possible when completing this form. The more information you provide the more effective we can be and the less likely we will need to interrupt your day to seek more information. Thank you for your cooperation.

Your Details

Debtor Detail

Debt Details

Attempted Recovery Details

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