Prushka Fast Debt Recovery

Online Action Form


Debtor	Your Particulars
Type of Debts

Prushka Client No:				Name:
Name/Trading Name:
Your Postal Address:				State:		Postcode:
Contact Name:				Email:
Telephone:		Fax:			Mobile:
Nature of Business:						ABN:
Have you used Prushka before?
OTHER INFORMATION
Comment:
Please attach any relevant Information:			(Please limit your attachment to a maximum of 500KB)

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.
Date:	08/09/2010	Name:			Position:
(Note: By typing your name above this constitutes your signature)					(State Position if Signing on behalf of a business)

FOR IMMEDIATE ACTION SUBMIT COMPLETED FORM NOW! Enquiries - Call the Prushka Client Services Team - Freecall 1800 061 761
PARTICULARS OF THE BUSINESS WHICH OWES YOU MONEY
Business Name:						ABN:
Contact Name:				Email:
Postal Address:				State:		Postcode:
Telephone:		Fax:			Mobile:
PARTICULARS OF THE PERSON WHO OWES YOU MONEY
Full Name:
Home Address:
State:		P/C:			Email:
Telephone:		Fax:			Mobile:
Work Details:	(If known)
Name of Relation:	(If known)
FOR MEDICAL DEBTS ONLY
Name of Patient:
Referring Doctor Name:				Date of Consultation/Service (dd/mm/yyyy)
Date of first invoice:		dd/mm/yyyy		Balance Owing:$
Add Prushka Commission?		(Only select option if your trading terms allow you to do so. Call Client Services Team to explain further)
FOR WORKCARE OR MOTOR ACCIDENT BOARD CLAIMS
Claim Number:				Date of Accident:(dd/mm/yyyy)
Name and Address of Patient's Employer:
State:		P/C		Insurer:
MONIES OWING
Date of first invoice:		dd/mm/yyyy		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)

OTHER INFORMATION

PARTICULARS OF THE BUSINESS WHICH OWES YOU MONEY

PARTICULARS OF THE PERSON WHO OWES YOU MONEY

FOR MEDICAL DEBTS ONLY

FOR WORKCARE OR MOTOR ACCIDENT BOARD CLAIMS

MONIES OWING