Name of Business:                                                             


Individual Responsible:                                       Phone Number:                                            
                           

Fax  Number:                                                               Email:    


Address:                                                        Zip Code:    


Invoice # :             Percentage Rate:                         Initials:C.L.G.                     Details:                                             



 Debtor's Name:                          Address:                      City/State/Zip:                         


 
Phone #                                                    Fax #
 





  This agreement shall remain in effect until Client submits express written notice to agency. Clients represents that all accounts placed with agency are legally due and owing and will provide documentation if requested. We grant GUICE SPECIALISTAND MATHIS the power of attorney to the above account(s). We authorize GUICE SPECIALIST AND MATHIS to collect amounts owing, any additional interest and collection fees that are due us legal and just. Commission will be charged on any funds collected; paid directly to clients or settled by negotiations or return of merchandise. A cancellation fee will be charged on any account that is inappropriately canceled or due to interference from client once GUICE SPECIALIST AND MATHIS has been obtained. Cancellation fees will be full fee due or 1% of balance. Waiver of cancellation fees will be based upon just cause. You the agent for your company authorizes GUICE SPECIALIST AND MATHIS to accept payments and to endorse checks, notes, money-orders or drafts for deposits; the net process of which you are to remit to GUICE SPECIALIST AND MATHIS. Special authorization is required to file suite, compromise or grant an extension.


Authorized By:                                                          Date:                                                                          


For Interoffice Use Only Client #                                            Debtor #                                       

     Collector: