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:	*
:	Existing ClientNew Client
First Name:	*
Last Name:	*
ABN/ACN:
Business Address:
Postcode:
Is the street address your postal address?:	YesNo
Postal Address:
Postcode:
Phone Number:	*
Mobile:
Email Address:	*
------------------------------------------------------------------------------------------
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:	NoYes
Occupation:
Current Employer:
Previous Employer:
Known Assets:
Other:
------------------------------------------------------------------------------------------
Debt Details
Debt Relates to:	Select...Work Done & Materials SuppliedGoods Sold & DeliveredServices RenderedProfessional Services RenderedMoney LentRent OwingGuaranteeDamage to PropertyExisting Judgment or OrderOther *
Date of Debt:	*
Balance Owing:	*
Copy of Invoice:
Copy of Invoice:
Is Interest Recoverable:	NoYesI'm not sure
Rate %:
Are collection costs recoverable?:	NoYesI'm not sure
On what basis?:
State:	Select...NSWQLDVICSATASACTNTWAI would like to discuss this with an Operator *
------------------------------------------------------------------------------------------
Attempted Recovery Details
Is the debt disputed?:	NoYes *
	Please take the Disputed Approach. I acknowledge a fee of $250 (plus GST) is payable on set up.
	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?:	NoYes
On which date?:
What happened?:
Do you have any security for payment (eg Mortgage, charge, retention of title):	NoYes
Please describe:
Is there a Guarantor?:	NoYes
Name:
Address:
-------------------------------------------------------------------------------------------
Please take the following approach:	Direct ApproachCustomised Approach
Please take the following approach:	Disputed 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):	*