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FORM 'B' ADD TO DATABASE - CONSUMER

From
Membership Number
Date 19 May 2012
Please add the following defaulter to the data base as indicated below until further written notice:
First Name or Initials  *  
Individual's Surname  *  
Identity Number  *  
 
Address 1  *   
Address 2  *  
Address 3  *
Postal Code  *  
Telephone  *  
Fax  *  
 
Reason (Goods or Service)
Amount Outstanding  *
Date Outstanding Select date  *
Captured By  *  
Special Instructions
 
Do you have signed surety?
 
Do you require legal assistance at the pre-negotiated rates (Contingency Basis)?
 
Please Note :

No refund will be given should this letter be unclaimed or returned due to the incorrect / insufficient information received.
Agreement :
We accept the disclaimer from Accountability as agreed to on our membership application.
Please deduct the once off fee as indicated above from our bank account.
We assure you that the above information is true and correct and when clicking on the submit button accept this submission as your approval for Accountability to proceed.
 
 

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