Consumer Collections Form - Affinity Credit Solutions

You must have an active agreement in place to ensure we can start working on your listing.
If this is your first account, complete this now.

Your Information

First Name*

Last Name*

Company Name

Address*

City*

Province*

Postal Code*

Phone*

Email Address*

Debtor Information

Debtor 1

First Name*

Middle Name

Last Name*

Date of Birth (YYYY/MM/DD)

Address*

City*

Province*

Postal Code*

Phone

Cellphone

Email Address

Customer Account #

Place of Employment

Employer Phone

Debtor 2

First Name

Middle Name

Last Name

Date of Birth (YYYY/MM/DD)

Address

City

Province

Postal Code

Phone

Cellphone

Email Address

Customer Account #

Place of Employment

Employer Phone

Balance Information

Principal Balance Due*

Interest Balance Due

Total Balance Due*

Interest Rate (If Applicable)

Date of Last Payment

Last Date of Service*

Date of Last Acknowledgement*

Date of First Delinquency* ?

Supporting documents (Supported file types: jpg,pdf,docx. Each file must be under 2MB.)

The types of supporting documents are:

Agreements
Credit Application
Invoices
Statements

Choose a file…

Other Information/Reason for Debt

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