Order Form (Collect)- Special Rate

Company Information:

Company Name: (required)

Attn: (optional)

Address: (required)

City: (required)

State: (required)

Zip: (required)

Phone (required)

What is your Industry (required)
---MedicalDentalEducationEnergyFinanceAutomotiveGovernmentConstructionLegalTechnologyUtilityOther

Primary Contact:

Your Name: (required)

Your Email: (required)

Kinum's Collection Service Fees:

(You are signing up for Contingency Collections : No payment required)
Kinum's Commission Fees:
33% : If less than 1 year old
33% : If more than 1 year old
50% : Legal
50% : Mail Returns

Questionnaire: (Optional)

Credit Reporting?
If you select "yes", you authorize Kinum to report Step 3 debts to the credit bureaus on your behalf. You agree to abide by all rules set forth by the Fair Credit Reporting Act (FCRA).
NO - Do not report to Credit BureausYES - Please report to Credit Bureaus

What AR Software do you use?
NoneAtnenaHealthPulseQuickBooksRaintreeOther

Terms and Service Agreement

I have read and accepted the Privacy Policy & Terms of use

I have read the Service Agreement and e-Signing it by checking the box