Name (authorised signatory) *
Position *
Registered Company Name (the client) *
Registered Company Address *
Company Registration No. *
Telephone *
Fax
Email *
Preferred Contact Name/Tel (if different from authorised signatory above)
Type Of Company * If other please specify
Nature of Business *
Country of incorporation


* denotes a required field
Intrum Justitia reserves the right to refuse any application.