| First Name: | |
| Last Name: | |
| Address Street 1: | |
| Address Street 2: | |
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| Email: | |
| Daytime Phone: | |
| Zip Code: | (5 digits) |
| Evening Phone: | |
| Whats is the best time to call you?: | |
| Would prefer to speak with someone in Spanish?: | |
| Where did you hear about us?: | |
| If You Referred To Us Tell Us Who Referred You: | |
| Have you ever or do you currently have any loss of license complaint's or fine's?: | |
| If Yes Explain: | |
| E&O Company Name: | |
| E&O Contact Name: | |
| E&O Contact Fax: | |
| E&O Contact Phone: | |
| E&O Policy#: | |
| E&O Coverage Amount: | |
| State Lic Division?: | |
| State Lic Board?: | |
| State Lic Type? | |
| State License #?: | |
| Expiration Date: | |
| State Licensed: | |
| Company Name: | |
| Company Address: | |
| City: | |
| State: | |
| Zip: | |
| Office Phone: | |
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| Web Site:: | |
| Tell us about your credit ?: | |
| How many costumer's have you serviced last year?: | |
| How many new costumer's do you service monthly: | |
| How are you currently generating your business?: | |
| How would you market the RemoveMYbills name to gain exposure in your area?: | |
| What is your monthly marketing budget?: | |
| What Services Do You Offer? | |
| What zip codes can you service?: | |
| Do you believe in the customer satisfaction?: | |
| Personal skills, strengths and experience that you have that will make you an asset to our company: | |
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| | I Accept To Receive Customer Leads & I Agree To Offer My Best Professional Service To Them. Failure to comply will result in immediate termination of membership. |
| | I Have Read & Agree To RMB Terms Of Use & Privacy Notice. Failure to comply will result in immediate termination of membership. |
| | I Certify That The Information Above Is Correct & That I Hold The Correct Licensing To Offer The Service's
Advertised On The Web Site.
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