SUBMIT NEW BUSINESS CBM Client Information<hr>Field is required!Field is required!New CBM clients please fill in all client fields. Existing CBM clients only need to fill in Client Name and Collection Type. Field is required!Field is required!Client NameField is required!Field is required!Phone NumberField is required!Field is required!EmailField is required!Field is required!Client Account Number:Field is required!Field is required!Authorized By[{"field":"{New_CBM_Client}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Collection Type- select a option -Standard CollectionPrecollect- select a option -Field is required!Field is required!Debtor Information<hr>Field is required!Field is required!First NameField is required!Field is required!Last NameField is required!Field is required!Name Of Responsible Party (if any)Field is required!Field is required!Know Account Number?YesNoField is required!Field is required!Debtor Account NumberField is required!Field is required!Date Of ServiceField is required!Field is required!Charge-Off DateField is required!Field is required!Know Date of Last Payment?YesNoField is required!Field is required!Date Of Last PaymentField is required!Field is required!Beginning Balance From DOSField is required!Field is required!Accrued InterestField is required!Field is required!Fees and PenaltiesField is required!Field is required!Payments or AdjustmentsField is required!Field is required!Current Balance Placed For CollectionsField is required!Field is required!Debtor Phone Phone NumberField is required!Field is required!Responsible Party Phone (if any)Phone NumberField is required!Field is required!Know Address of Debtor?YesNoField is required!Field is required!AddressField is required!Field is required!Address 2[{"field":"{known_debtor_address}","logic":"","value":"no","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!CityField is required!Field is required!StateField is required!Field is required!Zip CodeField is required!Field is required!Know SSN of Debtor?YesNoField is required!Field is required!Social Security NumberField is required!Field is required!SSN of Responsible Party (if any)Social Security NumberField is required!Field is required!Know DOB of Debtor?YesNoField is required!Field is required!Date Of BirthField is required!Field is required!Responsible Party DOB[{"field":"{dob_option}","logic":"","value":"no","and_method":"or","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Place Of EmploymentField is required!Field is required!Place Of Employment PhoneField is required!Field is required!Spouse Information<hr>Field is required!Field is required!First NameField is required!Field is required!Last NameField is required!Field is required!Date Of Birth[{"field":"{dob_option}","logic":"","value":"no","and_method":"or","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Social Security NumberField is required!Field is required!Phone NumberField is required!Field is required!Is Spouse Responsible Party?YesNoField is required!Field is required!Additional InformationField is required!Field 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
