Name :
      
  Phone :      
  Address :      
  City/State/Zip :      
  Amount :      
  Representative :      
  Date oldest unpaid invoice :      
  Date last unpaid invoice :      
  Account / invoice number :  
  Additional Amount (interest) :  
  Name of individual responsible :  
Facts (any pertinent info on your collection efforts) : 

        
 

Please provide any of the following information if available; Credit application, bill of lading, and proof of delivery, personal guarantee, and any invoices.

Client Information
We the undersigned as the client hereby grant power of attorney over all placed account(s) with SIMMONS & ADAMS and authorize S&A to negotiate and collect the placed accounts(s). Commissions will be charged on all accounts paid to S&A or client directly after placement, or where value is received by the client, e.g. by return of merchandise. A ten percent cancellation fee shall apply on all accounts placed if withdrawn by the client. If litigation is necessary, we direct you to consult us, and select an attorney for placement. We authorize S&A to settle and / or accept payments,endorse checks, notes, money orders, bank drafts, or otherwise conduct any lawful transaction. S&A will remit the net proceeds after your commission to the address below. Any disputes shall be solely litigated in Houston, Harris County, Texas, under Texas law.

  
 
Your Company Name :
      
  Address:      
  City, State, Zip :      
  Phone:      
  Fax:      
  Authorized by:      
  Title :      
  Date :