Submit Online Instruction

Please select below to autorise the collection instruction?

You are authorised to proceed immediately with any / all appropriate actions to collect.

Please provide us with the Debtor information (The person you wish us to proceed against)

Full Name/s of Debtor:*
Full Surname of Debtor:*
Date of Birth:
Identity No.:
Home Address:*
New or Old
Postal Code:
Postal Address:
Postal Code:
Name of Employer:
Work Address:
Postal Code:
Home Telephone No.:
(code and number)
Cellular Number:
Work Telephone No.:
(code and number)
(code and number)
Email Address:
Hand Over Amount:*
(principal capital amount)
Hand Over Interest Amount:
Nature of the Debt:*
Date of Oldest Outstanding Invoice:
Place of Agreement:*
Date of Most Recent Outstanding Invoice:
Date of Last Payment:

Next of kin details:

Home Address:
Postal Code:
Home Phone:
Cellular Number:
Work Phone:
Email Address:

Please supply a brief description of the debt and the reasons why the debtor is not paying you.

Additional Comments

Please provide us with your details so that we may respond to your request.

Company Name / Name:*
Physical Address:
Postal Code:
Postal Address:
Postal Code:
Contact Person:
Contact No.:
(code and number)
Your Name:
Email Address:*

Please fax copies of the following to 041 373 2593

Statement of account (tick if you do not have this documentation)
Invoice copies (tick if you do not have this documentation)
Proof of delivery (tick if you do not have this documentation)
Credit application or underlying contract (tick if you do not have this documentation)
Personal guarantee (tick if you do not have this documentation)

Collection Rates (calculated from the oldest invoice date)

Invoice Age Commission Rate

Age of the debt is determined from the last date of the last payment, or in event that no payment was received, the date of last purchase/service rendered.

  • 0 to 30 days 10%
  • 30-60 15%
  • 60-90 20%
  • 90-120 25%
  • 120-150 30%
Our Terms and Conditions

* We refer the above account(s) to you for collection and you are authorised to proceed at once to collect the above amount. Commission will be charged on amounts collected, paid direct to me or settled by return of merchandise. In the event litigation deems necessary, we direct you, as our agent, to send the account to an insured and bonded attorney. You are authorised to accept payments and to endorse notes, money orders or cheques drafts for deposit; the net proceeds of which you are to remit to us. Please report all payments received at your office immediately.

Please indicate that you agree to our terms and conditions?

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