Advantage 2K Medical Billing Company
Application for CMRS Exam
Form Number MHEC-cmrs
Name:
Address:
City:
State:
Zip Code:
Phone Number: (day and evening)
Company Name:
Email Address:
Your Computer Operating System: ___Win98 ___WinMe ___WinXP ___WinNT ___Other______________
Date graduated from High School or GED Date:
School Attended:
Date you joined AMBA:
If not a member yet, please complete the membership application
and include it along with this application and membership dues.
Education and or Training:
Work Experience:
How long have you been in business?
Do you hold other certifications, if yes, please list:
Purchase Info
___CMRS Exam $325
___CMRS Study Materials $199
Total:
Payment Type:
[ ] I payed for exam online
[ ] Business Check
[ ] Personal Check
[ ] Visa
[ ] Master Card
[ ] Discover
Card Number:
Expiration Date:
Name on Card:
Signature:
Mail Application to AMBA Main Office Or Fax to (580) 622-5809
AMBA
4297 Forrest Drive
Sulphur, OK 73086
(580) 622-2624
Email Us
This form generated from AMBA East Coast Office