Head Office:

Level 4

488 Bourke Street

Melbourne VIC 3000

Telephone: 1300 471 772

Email: support@piranhacollect.com.au

www.piranhacollect.com.au

SUBMIT DEBT FORM

FOR INDIVIDUALS (Our Client):
- Please complete all fields

Name (required)

ABN

Postal Address

Business Address

Driver Licence #:

State of Driver licence issue:

Contact Telephone Home:

Contact Telephone Business:

Mobile

Your Email

FOR COMPANY (Our Client):
- Please complete all fields

Company/Business Name:

ACN

ABN

Postal Address

Business Address

Contact Telephone Business:

Contact Person No 1:

Title:

Mobile

Email

Contact Person No 2:

Title:

Mobile

Email

Acknowledgement

I, acknowledge that Piranha Collection Services Pty Ltd (“Piranha Collect”) will not undertake any debt collection activities until such time as the Terms and Conditions ( found here) of Piranha Collect are executed between the parties.
Tick to Accept:

I have read and executed the Terms and Conditions ( found here) and agree to be bound them and by the rates ( found here) and elect: .Tick to accept & confirm:

I am authorised by the client to give instructions in relation to any of the client’s customer/s the subject of debt recovery in which Piranha Collect is engaged. Tick to Confirm:

DEBT COLLECTION:

Should multiple debts exist for recovery please contact Paul Pattison on 0401008777 to arrange batch data collection or alternatively complete the page titled Data Input Form ( found here) or at www.piranhacollect.com.au.

Debt 1 Full Name of Debtor:

Debt 1 Full Name of Contact person:

Debt 1 Business Address:

Debt 1 Debtor Business Telephone No:

Debt 1 Debtor Mobile No:

Debt 1 Debtor Email Address:

Debt 1 Your Debtor Account Reference No:

Debt 1 Total Owing:

Debt 1 Date of Debt/s:

Debt 1 Is interest Recoverable?:YesNo

Debt 1 If interest recoverable detail rate of interest:

Debt 1 If interest recoverable provide copy of Agreement:

Debt 1 Are Collection Costs recoverable:YesNo

Debt 1 If Collection Costs recoverable provide copy of Agreement:

Debt 1 State within Goods or Services provided:

Debt 1 Does a Judgment Debt / Court Order exist? :YesNo

Debt 1 If Judgment Debt / Court Order exist – provide copy:

Debt 1 If no Judgment or Court Order include copy of invoice/s:

Debt 1 Include copy of any correspondence to / from Debtor:

Debt 1 Is the Debt disputed?:YesNo

Debt 1 If Debt is disputed - provide reasons/ copy correspondence:

Debt 1 Is the Debt Secured?:YesNo

Debt 1 If Debt is secured - provide description of security:

Debt 1 Is the Debt Guaranteed?:YesNo

Debt 1 If Debt Guaranteed provide details of Guarantor/s (Name / Address/ Email/ Telephone No.):

Additional Information: (Please provide as necessary).

I confirm I am the person authorised by the client to enter into these Terms and Conditions.

Date Authorised:

Your Name:

Your Position:

Your Signature:

How Did You Find Us?

If a personal referral provide Name/Email/Telephone number of referrer:

* For multiple debts please complete this page for each debt to be collected.

Submit Debt

SUBMIT DEBT FORM