Company and Primary Contact Information

How did you hear about Unifund?*	If other, please describe:
<--Select--> Advertisement Unifund Customer Industry Meeting Website Unifund Partner Other

Company Name:*	Title:	Federal Tax ID:
First Name:*	Last Name:*	Suffix (Jr.,Sr.,III):
Street Address:*	Suite/Floor:
City:*	State:*	Zip/Postal Code:*	Country:
	<--Select--> Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
PO Box:
Company Main Phone Number:*		Direct Phone Number:
Ext.		Ext.
Cell Phone Number:	Fax Number:	E-mail Address:
Website Address:
Type of Organization: (Please Select) Collection AgencyAttorneyREO BuyerTitle Company Collection Law FirmDebt BuyerForeclosure AttorneyOther If other, please specify:
What % of accounts do you litigate?: (Please Select) 100%75%50%25%10%0%

Debt Buying Experience

Have you ever purchased debt?
YesNo
Types of debt you purchase: (Check all that apply)
Auto DeficiencyBankruptcyCredit Card/Bank Charge Card Credit Union Charge CardChecksCommercial Consumer LoansDeceasedGovernment Healthcare/MedicalInternationalJudgments Lines of CreditMortgageOil/Gas Charge Card Student Loans (Non-government)Sub-PrimeTelecommunications Utility
Preferred Average Balance: (Please Select All That Apply)
Under $1,000$1,000 - $5,000 $5,000 - $10,000Above $10,000
Preferred Account Age: (Please Select All That Apply)
Pre-charge off4th Placement At charge offWarehouse 1st PlacementNear Out-of-Statute 2nd PlacementOut-of-Statute 3rd PlacementNo preference
List any geographical preferences:		Number of Previous Purchases:
Size of Last Purchase (Total dollars spent):
Next Purchase Amount:
Expected Closing of Your Next Portfolio Purchase: (Please Select)
Immediately (in 7 days)Within 1-3 MonthsWithin 6-12 Months Within 4 WeeksWithin 3-6 MonthsNo preference

Company Information

Corporate Status: (Please Select)
Sole ProprietorshipCorporationLimited Liability Corporation PartnershipOther If other, please specify:
State of Incorporation:	Years in Business:
<--Select--> Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming U.S. Territory Puerto Rico Guam U.S. Virgin Islands American Samoa
List all owners, partners, or officers:
Number of Employees:
Collectors		Attorneys
Management/Administration		All Other
In the last 10 years, has your company or any of its owners been convicted, litigated or investigated regarding your business practices or activities related to the buying/selling of financial assets/securities?
YesNo
Do your business practices adhere to state and federal regulations?
YesNo
What organizations/associations does your company belong to?

Trade References

Please provide two business references:

Entity Contact Phone Ext.

Entity Contact Phone Ext.

All statements and information provided in this application are true. I have verified the accuracy of the statements and information provided in this application. I have the authority to submit this application on behalf of my company/organization.

I Accept

Name of person completing this application:

Yes, please email me with offerings from Unifund.

General comments or requests:

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