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CISCO Inc.

800-231-3686

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Welcome to our Online Account Placement Form.

Please fill out the information below to place your accounts.

Date

Assigned By Client # (If Known)

Client Company Name

*

Client Contact Title

Client Contact Name

*

Client E-mail Address

*

Client Contact Telephone Number

Client Fax Number

Client Address

Client City / State / Zip Code

Assigned By Name

*

Service Desired

Debtor Information

Client Reference Number

Additional Client Reference Number

Debtor Company Name

*

Debtor Primary Telephone Number

*

Debtor Secondary Telephone Number

Debtor E-mail Address

Debtor Address

*

Debtor City / State / Zip Code

*

Debtor Fax

Last Invoice Date

*

Balance Due

*

Debtor Bank

Debtor Entity

Contract

Promissory Note

Bad Check(s)

Itemized Statement

Invoices

Statements

Credit Reports

Credit Application

Correspondence

Collection Notes

Other Documents

Not Applicable

Please Indicate if you...

Additional Comments

Do not enter anything in this field:

* indicates a required field

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Home
About Us
Services
Fees
Account Placement
Client Access
Pay My Account
Contact Us

CISCO, Inc.
Phone: 800-231-3686
Email: Info@ciscocollect.com