Client Registration Form

Please use this form to register for an account. Registration allows you to submit accounts to Nationwide Management Services, Inc. for collection services based on your collection agreement with our company. If no agreement exists with our company, one will be provided to you prior to accepting any accounts for collection. If you have any questions, please contact us at 800-682-5190 prior to completing this form.

Note: We currently only accept establish NEBRASKA commercial, business and medical accounts!

Client Name:  
Client Street -1:  
Client Street -2:  
Client City:  
Client State:  
Client Zip:  
Client Business Phone:  
Client Fax:  
Client Contact Person:  
Client User Account Number:  
Client User Password:  
Client Email: