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Online Placement Form

Step 1 - Placement Information Entry

This form has been developed to make your job of sending business to CMI easier.  This process has been divided into 3 steps.  The "placement information entry"; "the review and submission", and the "confirmation". Fields with a * next to them are mandatory, all other fields will only assist our team in collecting your money faster.

If you are trying to place an international account,
please click the button below!!
 

 

PLEASE DO NOT USE APOSTROPHES!!!

 

Domestic Debtor Information

 
*Debtor's Name:  
*Debtor's Street Address:  
Debtor's PO Box:  
*Debtor's City:  
*Debtor's State:  
*Debtor's Zip:  
Debtor's Phone:  
Debtor's Fax:  
Debtor's Email Address:  
 
 

Invoice Information

 
Customer Account Number:  
Number of Open invoices:  
*Date of Oldest Open Invoice:  
Date of Newest Open Invoice:  
Date of Last Payment:  
Additional Invoice information (i.e. invoice numbers):  
   
 

Principal or Owner Information

 
Name/Title:  
Address:  
Phone:  
Name/Title:  
Address:  
Phone:  
   
 

Comments or Story

 

   
 

Debt Information

*Principal Amount Owed:   $
Interest Amount Owed:   $
Collection Charges Owed:   $
Miscellaneous Charges Owed:   $
TOTAL AMOUNT OWED WILL BE DISPLAYED ON THE CONFIRMATION PAGE