"; $receipt .= "Your claim has been submitted. Please print out this page for your reccords.\r\n"; $receipt .= "Date:".$_POST['date']."\r\n"; $receipt .= "Debtor:".$_POST['debtor']."\r\n"; $receipt .= "Address:".$_POST['address']."\r\n"; $receipt .= "Principal Name:".$_POST['name']."\r\n"; $receipt .= "Principal Phone:".$_POST['phone']."\r\n"; $receipt .= "Amount Due:".$_POST['due']."\r\n"; $receipt .= "Debtor's Bank:".$_POST['bank']."\r\n\r\n"; $receipt .= "Client's Information\r\n\r\n"; $receipt .= "Authorizing Name:".$_POST['authorizing']."\r\n"; $receipt .= "Company Name:".$_POST['company']."\r\n"; $receipt .= "Address:".$_POST['address1']."
".$_POST['city']."\r\n"; $receipt .= "Phone Number:".$_POST['phone1']."\r\n"; $receipt .= "Fax Number:".$_POST['fax']."\r\n"; $receipt .= "Comments:".$_POST['comments']."\r\n"; $receipt .= "
"; $receipt .= ""; $receipt .= ""; $receipt .= ""; $receipt .= ""; $receipt .= ""; $receipt .= ""; $receipt .= ""; $receipt .= "
"; foreach($HTTP_POST_VARS as $key => $value) { if ($key != 'name' && $key != 'phone' && $key != 'comments' && $value == '') { $errorCount++;; } } if ($errorCount == 0) { // Send the e-mail mail('info@gotocri.com', 'New Claim Filed', $message, 'From: Claims'); $successCount++; } } ?> File a Claim
   
 
   
   
 
   
   
 
   
   
 
   
   
 
   
 
   
   
 
   
   
 
 
"; ?>
For Immediate Collection Action
"; if ($errorCount > 0) { echo "Please enter all required information"; } elseif ($successCount > 0) { echo "Your claim has been submitted. You may now enter another claim."; } echo "
 
 
Date:
  
 
 
Customer Number:
  
       
 
Debtor:
  
 
 
Address:
  
 
 
Principal Name: (commercial only)
  
 
  Principal Phone:  
 
 
Amount Due:
  
 
 
Debtor's Bank
  
 
Please proceed with IMMEDIATE COLLECTION subject to your rates of our claim against the above named debtor with authority for you to collect, sue (with our specific consent) and receive payment thereof. It is our understanding tha tthis account may be withdrawn at any time for any reason without penalty, prior to collection. We warrant that this claim is true, just and owing and free from offset or counterclaim, and shall report all payments and communications received from debtor.
 
SPECIAL INSTRUCTIONS/COMMENTS
 
 
Authorizing Name:
 
 
 
Your Company Name:
  
 
 
Address:
  
 
 
City & State:
  
 
 
Phone:
  
 
 
Fax Number:
  
       
  E-mail  
 
 
Additional Comments :
  
 
 
Our Motto: “Sooner or Later you’re going to pay the Pipher!”