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Amount Owing $*:
Date Incurred/Invoice Date:
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Please provide a brief explanation of the reason for this debt/dispute*:
Do your terms of trade have a debt collection clause*:
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By accepting these terms, you agree to authorise CIA Debt Recovery Ltd to act as your agent in the above matters and agree to make payment of all charges and costs in accordance with the current terms and conditions.
You agree to not proceed to legal action, nor take independent action by another means through an agency or, on your own accord, against this debtor without first consulting CIA Debt Recovery Ltd.
If you do take independent action or/and if any monies are paid to you or your agent, by the debtor, CIA Debt Recovery Ltd will invoice you for the full commission that relates to the option you have chosen above and any subsequent enforcement costs.
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