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C.D.R.S. client ref:
Have you ever used C.D.R.S before? YES NO
CLIENT DETAILS
Your Name:
Trading Name:
Address:
Postcode:
Phone:
Fax:
Email:
Contact:
DEBTOR'S DETAILS (COMPANY/BUSINESS)
Company Name:
Contact:
Address:
Postcode:
Phone:
Fax:
A.C.N:
DEBTOR'S DETAILS (PERSONAL)
Debtor's Name:
Home Address:
Postcode:
Business Address:
Postcode: 
Phone (home):
Phone (business):
Fax:
Mobile:
MONIES OWING
Amount of debt as per invoice: $
Balance Owing: $
Date of first invoice:
Details of service or goods provided by you
FOR MEDICAL CLIENTS ONLY
Patient's Date of Birth (dd/mm/yy):
Medicare No:
Referring Doctor:
Date of Service
(dd/mm/yy):
Phone:
I,   declare that I am a person authorised by the Client to give these instructions and I confirm that I have read and understand the terms and conditions.

Incorp Pty Ltd (ACN 005 979 224) t/a Commercial Debt Recovery Solutions is not part of Carew Counsel Pty Ltd Solicitors and your request to authorise C.D.R.S. to act constitutes acknowledgement of this fact.
Date (dd/mm/yy):
Name:
Position:
 
Australian Wide Collection
Address
Level 7, 555 Lonsdale Street
Melbourne Vic 3000

Phone
+61 3 9670 4109

Fax
+ 61 3 9670 2226

Email
Click here to Email Us
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"Commercial Debt Recovery Solutions are our first choice in making sure that all the debts we are
                              owed are repaid quickly and without any unnecessary stress"
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