SUBMIT NEW BUSINESS CBM Client InformationNew CBM clients please fill in all client fields. Existing CBM clients only need to fill in Client Name and Collection Type. Client NameField is required!Phone NumberField is required!EmailField is required!Client Account Number:Field is required!Authorized By[{"field":"{New_CBM_Client}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Collection Type- select a option -Standard CollectionPrecollect- select a option -Field is required!Debtor InformationKnow Account Number?YesNoField is required!Debtor Account Number[{"field":"{know_debtor_account_number}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Account BalanceField is required!Date Of ServiceField is required!Know Date of Last Payment?YesNoField is required!Date Of Last Payment[{"field":"{know_date_of_last_payment}","logic":"","value":"no","and_method":"or","field_and":"","logic_and":"","value_and":""}]Field is required!First NameField is required!Last NameField is required!Name Of Responsible Party (if any)Field is required!Know Address of Debtor?YesNoField is required!Address[{"field":"{known_debtor_address}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Address 2[{"field":"{known_debtor_address}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!City[{"field":"known_debtor_address","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!State[{"field":"known_debtor_address","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Zipcode[{"field":"known_debtor_address","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Place Of EmploymentField is required!Know SSN of Debtor?YesNoField is required!Social Security Number[{"field":"{ssn_option}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!SSN of Responsible Party (if any)Social Security Number[{"field":"{sos_option}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Debtor Phone Phone NumberField is required!Responsible Party Phone (if any)Phone NumberField is required!Place Of Employment PhoneField is required!Know DOB of Debtor?YesNoField is required!Date Of Birth[{"field":"{dob_option}","logic":"","value":"no","and_method":"or","field_and":"","logic_and":"","value_and":""}]Field is required!Responsible Party DOB[{"field":"{dob_option}","logic":"","value":"no","and_method":"or","field_and":"","logic_and":"","value_and":""}]Field is required!Spouse InformationFirst NameField is required!Last NameField is required!Date Of Birth[{"field":"{dob_option}","logic":"","value":"no","and_method":"or","field_and":"","logic_and":"","value_and":""}]Field is required!Social Security Number[{"field":"{sos_option}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Phone NumberField is required!Is Spouse Responsible Party?YesNoField is required!Additional InformationField is required!Submit New Business Listing Sheets Print form in Microsoft Word. Fill out and fax to 989-631-0705 » New business listing sheet HIPPA Compliance » Business Associate Agreement