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Credit Bureau of Jonesboro, Inc.
Collection Division
P O Box 1305
109 E. Jackson
Jonesboro, Arkansas 72403
932-6699
(800) 495-6646

Fields that are red are required for processing
Your Email Address:

Creditors No.:
Name:
Date:
Address:
City: State: Zip: Phone No.
Authorized by: Title:

Listing Sheet
The Accounts Shown Below Are Herby Listed For Collection:
Name of Responsible Party:
 Spouse:
 Phone Number:
 Social Security #:

Address:
 City:
State:
 Zip:

Employment:
Employers Address:
 Creditor

Amount Due:
 Date of last service or payment:
 Debtors Acct. #:
 Referred By:

Contact Name:
 Contact Number:
 Age or D.O.B.:
 Former Emp.:

Comments:


If you wish to submit multiple accounts,
continue down the page and press the submit
button after the last account you wish to submit it.
2nd Account
Name of Responsible Party:
 Spouse:
 Phone Number:
 Social Security #:

Address:
 City:
State:
 Zip:

Employment:
Employers Address:
 Creditor

Amount Due:
 Date of last service or payment:
 Debtors Acct. #:
 Referred By:

Contact Name:
 Contact Number:
 Age or D.O.B.:
 Former Emp.:

Comments:


If you wish to submit multiple accounts,
continue down the page and press the submit
button after the last account you wish to submit it.
3rd Account
Name of Responsible Party:
 Spouse:
 Phone Number:
 Social Security #:

Address:
 City:
State:
 Zip:

Employment:
Employers Address:
 Creditor

Amount Due:
 Date of last service or payment:
 Debtors Acct. #:
 Referred By:

Contact Name:
 Contact Number:
 Age or D.O.B.:
 Former Emp.:

Comments:


If you wish to submit multiple accounts,
continue down the page and press the submit
button after the last account you wish to submit it.
4th Account
Name of Responsible Party:
 Spouse:
 Phone Number:
 Social Security #:

Address:
 City:
State:
 Zip:

Employment:
Employers Address:
 Creditor

Amount Due:
 Date of last service or payment:
 Debtors Acct. #:
 Referred By:

Contact Name:
 Contact Number:
 Age or D.O.B.:
 Former Emp.:

Comments:


If you wish to submit multiple accounts,
continue down the page and press the submit
button after the last account you wish to submit it.
5th Account
Name of Responsible Party:
 Spouse:
 Phone Number:
 Social Security #:

Address:
 City:
State:
 Zip:

Employment:
Employers Address:
 Creditor

Amount Due:
 Date of last service or payment:
 Debtors Acct. #:
 Referred By:

Contact Name:
 Contact Number:
 Age or D.O.B.:
 Former Emp.:

Comments: