DBA International Membership Application

Applicant
Company:
First Name:
Last Name:
Title:
Address:
City:
State:
Postal Code:
Telephone:
Fax:
E-Mail:
Confirm E-Mail:

Welcome and thanks for taking the time to fill out our application.
All entry boxes except fax is required on this form.

Member Type
	Professional
	Standard
	Affiliate
	Associate

Professional:
A special designation for those members who have purchased more than 30 portfolios or have spent $15,000,000 or more in capital on Debt Portfolios.

Standard:
The designation for companies who are seasoned debt buyers and they have purchased 15 or more portfolios or have spent $5,000,000 or more in capital on Debt Portfolios.

Affiliate:
The membership category for those who are not buyers, yet are involved in the industry. Affiliate members may be creditors or industry vendors.

Associate The automatic designation for first-time buyers or prospective buyers. The category for those companies who are new to the debt buying industry and have very limited or no industry experience.

References

Reference One

Company:
Contact:
Telephone:

Reference Two

Company:
Contact:
Telephone:

Reference Three

Company:
Contact:
Telephone:

Three references are required. They should be companies with whom you have had debt collection or debt purchase/sale transactions. Personal, banking or office supplier references are not acceptable.

Please make sure that the references you list are available, processing will be delayed if we cannot verify a reference.

Corporate Officers or Owners/ Shareholders

Name:
Title:
Percentage:

Name:
Title:
Percentage:

Name:
Title:
Percentage:

Name:
Title:
Percentage:

Name:
Title:
Percentage:

List all Corporate Officers or Owners/Shareholders indicating percentage of ownership of each.

Billing Information

Initiation Fee:	$ 275.00
Prorated Dues:	$
Total Amount Due:	$

	VISA	MasterCard
	Discover	AMEX
Card Number

CSC/CVV Number More information.


Expiration Date:
/

Name on card:
Check this box if Address is the same as above.
Address:
City:
State:
Postal Code:

Membership Costs

Initial Sign up Fee:	$275.00
Annual Dues:	$595.00
Total First Year Fees:	$870.00

Prorated Annual Dues:

Dec. 1 – March 31:	$595.00
April 1 – June 30:	$446.25
July 1 – Sept. 30:	$297.50
Oct. 1 – Nov. 30:	$148.75

Membership becomes active on approval of your application and receipt of your payment.

All Sales are considered final.