Prospects and Clients

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First Name

Last Name

Your Email

Your Phone Number

Contact Type


This is an attempt to collect a debt from a debt collection agency, any information obtained will be used for that purpose. I give my direct consent and express permission to any services and any collectors of my families’ accounts: to receive account communications, through various means such as 1) any cell, landline, or other number that I provide, 2) auto dialer systems, 3) voice mail messages 4) email messages 5) emergency contract information, and other forms of communications. This information will be securely stored and will not be sold.

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