Placements:

Please fill out this form and a Colex representative will contact you.

For consumer industries, please use this form

 

Online Placement Form

 
* - required field

About your company:

* Name   
Address   
Address 2   
City   
State   
(use "other" for out of USA)
Zip   
*Contact Person   
* Phone   
Fax   
Industry   
Email   

Documentation To Follow:

Email Documentation to:
Documents@colex.net

Mail Documentation to:
Colex International 
4940 Merrick Rd
Suite 311
Massapequa Park, NY 11762

Fax Documentation to:

Documentation that will be sent:

Invoice(s)
Contract
Credit Application
NSF (Checks)
Itemized Statement
Contact Notes
Proof of Delivery
Ad Copy
Retention Letter/Agreement

Debtor Information:

*Amount due to you
*Patient  
*Guarantor  
*SSN  
*Street Address 1  
Street Address 2  
*City  
*State  
(use "other" for out of USA)
*Zip Code  
Country  
Telephone  
Telephone 2  
Fax Number  
Employment  
Client Reference #  
Contact  Name/Title  
Email Address  

Please describe the services and/or products that you provided to your customer and when they were billed:




 
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