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Prushka Action Form

If you hate forms, call us on 1800 641 617 and we will gladly take your debt details on the phone.
You only need to complete your details once.

Step1: Confirm QLS membership Step2: Complete Debt Details
Step3: Tick on Terms & Conditions box Step4: Submit
Are you a member of QLS? Yes
Partnership No
*Compulsory FieldsPrint This Page
Are you a: *
Debtor: *
Your Email Address: *
Date of first invoice: *
Balance Owing: * $
Details of service or goods provided by you: *
Add Prushka Commission? *

(Only select option if your trading terms allow you to do so. Call Client Services Team to explain further)
Once you have lodged one complete Action Form, you can then submit debts to us by posting, faxing or emailing a copy of your invoice or print-out listing details of your debtors. As a member of QLS, you will receive a discount of
10% off Prushka's standard commission.
The terms which apply will be the current terms on our web-site.  
Details about work referring doctors, next of kin all helps.
Do you have an Attachment? *
Yes No
To assist with collection, it really helps to have a copy of the invoice for the debt.
Is Invoice Attached? *
Yes No
Please attach any relevant Information:
Please Note: Please limit to a file size of maximum 1MB with 4 attachments
I confirm that the above details are true and correct and that I have read the Terms and Conditions and agree to be bound by them.
Name: *
Typing your name above constitutes your signature
Position: *
Please state your position if signing on behalf of a business
a member of QLS
For Immediate Action Submit Completed Form NOW!

Please type what you see:

Enquiries - Call the Prushka Client Services Team - Freecall 1800 641 617
No More Forms.
To send future debts to Prushka, just quote your Prushka client number and email, fax or post copies of overdue accounts to us.