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DSG REFERENCE

BUSINESS INFORMATION

REPORT (BIR)

Your Company Name:

Company Name:

Name Trading As

(if applicable):

Company Number:

Postcode of

Demise Address:

Full Name of Proprietor 1:

Home Postcode of Proprietor 1:

Your

Address:

Your Reference:

Your Phone:

Your Fax:

Invoices Payable to:

CORPORATE ENTITIES NON-CORPORATE ENTITIES

CLIENT DETAILS

Debt Squared Group, Carnouse House, Kelvin Close, Birchwood, Warrington, WA3 7PB

Tel: 0800 002 9049 Fax: 0845 241 5006 Web: www.debtsquared.com Email: trac[email protected]om

Debt Squared Group Limited. Registered in England and Wales.

Reg. oce: St. Crispin House, St. Crispin Way, Haslingden, Rossendale, Lancashire, BB4 4PW

Company Reg No. 6729253 - VAT No. 978 3663 59

Charges: This service is charged at the rate of £15 + VAT per instrucon unless otherwise quoted.

Invoices are to be paid within 30 days.

*This form must be signed

Signature of Person Authorising Instrucon

Print Name:

Date:

Surveyor Name

Credit Control Name

Company Name

Telephone Number

By authorising this instrucon we conrm that we have read and accept the

Standard Terms and Condions of service.

Postcode of Registered Address:

Postcode of Trading Address:

Full Name of Proprietor 2:

Home Postcode of Proprietor 2:

Please complete as many details as possible.

Business Name:

Please complete as many details as possible.

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