DBA International Membership Application

Applicant
Company:
Contact:
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	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 membership category for those companies who are new to the debt buying industry and have very limited or no industry experience.

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 membership 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:	$

	Bill Me
	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:

January 1 – March 31:	$595.00
April 1 – June 30:	$446.25
July 1 – September 30:	$297.50
October 1 – December 31:	$148.75

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

All Sales are considered Final.