Facility Name:

Contact Person:

Phone:

Fax:

email:

Note: Please fill out the information requested below. We realize the numbers are going to be estimates only.

Please fill out your estimate of the current accounts that would be placed with HPRS.

 

ESTIMATED - ACCOUNTS TO BE PLACED EACH MONTH

Please fill out the following information about accounts that would be placed with HPRS at the end of each month.

1. Estimated age of the accounts would be days.

2. Estimated # of accounts turned over each month would be .

3. Estimated total dollar value of the accounts would be $.