PROOF OF DEBT LODGEMENT

My Wholesale Pharmacy Pty Ltd (formerly known as Pharmacy 4 Less Pty Ltd)

Creditor Name

Contact Name

Corporate Signing Options
I am the creditor personally. I am employed by the creditor and authorised in writing by the creditor to make this statement. I know that the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied. I am the creditor's agent authorised in writing to make this statement in writing. I know the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, unpaid and unsatisfied.

Trading As

ABN

ABN Not Applicable

Occupation

Address Line1

Address Line2

Suburb

Post Code

State

Nominated Email

Receive Reports Via Post

Receive Reports Via Email

Phone

Fax

Creditor Type

Total Claim Including Security

Claim Description

Reference No

Bank Account Name

BSB

Account Number

Do you have security?

Have you obtained judgement?

Was this a default judgement?

Is this debt guaranteed?

I have the following documents (tick as many as applicable):
Invoices

Letter Of Demand

Guarantee

Statements

Orders From Company

Credit Application

Judgement From Court

Statutory Demand