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    Name*

    Glasser File No.

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    This is a communication from a debt collector. This is an attempt to collect a debt. Any information obtained will be used for that purpose. You agree that we may respond to you by email.

    Completing this form does not establish an attorney-client relationship. Please do not include any information that is considered confidential.

    E-mail Authorization

    I would prefer to communicate with Glasser and Glasser, P.L.C. via e-mail. I understand that e-mail may not be as secure a method of communication as telephone or mail. By clicking the Agree button below, I waive any and all claims for damages in the event an e-mail is inadvertently disclosed to a third party or violates my privacy. I hereby authorize a representative from Glasser and Glasser, P.L.C. to communicate with me via the e-mail address I have provided and expressly release Glasser and Glasser, P.L.C. , its attorneys, officers, employees, clients and vendors from any liability resulting from e-mail communications.

    I attest that the e-mail address I have provided is not furnished or owned by my employer. I will also take steps to prevent the e-mail from going into the spam filter. Anyone who reads my e-mail always has consent to read all my e-mails, and this letter constitutes express consent.

    I also agree to act in a professional manner and not use unprofessional language or engage in e-mail abuse or harassment.

    This communication is from a debt collector. This is an attempt to collect a debt. Any information obtained will be used for that purpose.