Submit Account

Submit Your Account for Collections

Fill out the form below to place your account to Professional Collection Services Inc.

Your Information
Your Company Name:
Your Name:
Address:
City:
Province / State:
Postal Code:
Daytime Phone:
Evening Phone:
Fax Number:
Email Address:
Website:

Your Debtor Information
Debtor Company Name:
Debtor Contact Name:
Address:
City:
Province / State
Postal Code
Daytime Phone:
Evening Phone:
Fax Number:
Email Address:
Amount Owed:
Date Debt Incurred:
Date of Birth / Social Insurance #:
Was there a signed Contract?	Yes No
Do You Have Backup Such As Invoices:	Yes No
I Have Read the Terms of Service	Yes No
Is This A Judgment:	Yes No
If Yes, Date Judgment Was Awarded:
Product Or Service Provided:
Reason for Non-Payment:
Additional Information:
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