Phone: (705)264-5288
Fax: (705) 264-5284
 
Credit Bureau of Timmins Collects
ESTABLISHED CLIENTS
  
Client Information * = required field
Business Name:*


 Client#:*
Email:

I, the client listed above, hereby assign the following account(s) to Porcupine Credit Corporation (2001) Ltd..
(Operators of Credit Bureau of Timmins)

Please read our "Terms and Conditions"

* I have read and understood the usual terms and conditions.
 

Debtor Information
First Name:*

 Last Name:*
Address Line 1:

Address Line 2:

Address Line 3:
Is Mail Returned?
Yes
No
City:

Province/State:

Zip/Postal Code:
Phone Number 1:
 - -



Phone Number 2:
 - - 		       
SIN:
- - 		       
Date of Birth: (MM/DD/YEAR)
 / /
Marital Status:
Credit Card Number:

 Card Type:
Employer:

 Work Phone Number:
 - - X
Previous Employer:

 Phone Number:
 - - X
Landlord:
 Phone Number:
- -

Financial/Client Information
Client Reference #1:

 Client Reference # 2:
Date of Last Payment:
 / /
Date of Last Charge:
 / /

Amount Due:*
$ .      

Interest:
$ .      


Spouse Information

Spouse's First Name:

 Spouse's Last Name:
Employer:
 
Phone Number:
- -  X
Date of Birth:
/ /
SIN:
- -

Additional Information

Service Address (if different from mailing address):




Comments/Additional Information
example: Bank, Driver’s License, cell phone,
email, any other details.

Please double check all information before
submitting this listing.

 

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