Management Koncepts, Inc.

KK COMPANY, KOLLECTION KONCEPTS, CHECK KONCEPTS 

CLIENT ONLINE PLACEMENT FORM

* = Required Fields

Press to start again.

 

Client Name: Date (YY/MM/DD):
Client E-Mail: * Your name: *

Client Code: Please insert your Client Code for this type of work. If you have more than one client code i.e. #### = precollect ltrs; xxxx = regular collection accounts; XXXX= accounts over one year. If you are not sure please contact us for your Client Codes.

 

Debtor info: 

Check box if this is this a minor?YES
Amount Placed: Debtor Acct #:
Debtor Last Name:    
First Name: M.I.:
Address:    
City: State:
Zip:    
Place of employment: Tx Driver Lic #:
Debtor home phone: Work Phone:
Debtor/Patient SS #: NO DASHES!  

Date of Service (yy/mm/dd):

 Date of Last Pay (YY/MM/DD):
Guarantor / Spouse /2nd Name: Guarantor Phone:
Guarantor SS#: NO DASHES!  
Reference1 Name: Reference1 Phone:
Reference2 Name: Reference2 Phone:
Reference3 Name: Reference3 Phone: 

Comments:

Please enter the characters you see in the image: *

Image verification  Why?

If you cannot read the image, click for a new one 


CLICK SUBMIT AND YOUR INFO WILL BE SENT TO US BY ENCRYPTED EMAIL..

or press to start again.

 

This form and its free FormMail processor supplied by www.tectite.com.