Order Form (Collect)- Special Rate

Company Information:

Company Name (Legal): (required)

Company DBA Name: (optional - Required only if different from legal name.)
(If Doing Business As (DBA) name is provided, it will appear on the demands)

Attn: (optional)

Address: (required)

City: (required)

State: (required)

Zip: (required)

Phone (required)

What is your Industry (required)
—Please choose an option—MedicalDentalEducationEnergyFinanceAutomotiveGovernmentConstructionLegalTechnologyUtilityOther

Primary Contact:

Your Name: (required)

Your Email: (required)

Kinum's Collection Service Fees:

Kinum's Commission Fees:
33% : If less than 1 year old
33% : If more than 1 year old
50% : Legal
50% : Mail Returns

Questionnaire:

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

Settle in Full Authority:
Kinum always attempts to recover 100% of the amount owed from the debtor. However, sometimes a debtor agrees to pay a lower amount during Collection Calls (Step 3) to settle the case. We recommend 80%. You authorize Kinum to settle any accounts at or above the Settle in Full Authority percentage rate below.
100% - (Only settle for full amount)90% - (OK to settle at or above 90% of Amount Due)80% - (OK to settle at or above 80% of Amount Due)70% - (OK to settle at or above 70% of Amount Due)60% - (OK to settle at or above 60% of Amount Due)

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

Your Signature:

Please sign with touchpad or touchscreen: