Order Form: Fixed Fee Collection Service Connect is a fixed-fee written demands service. (You will also get access to our contingency-based Collection Calls Service.)Kindly enter your information below. Package selection & payment will be done on next page. Company Information: Company Name: (required) Attn: (optional) Address: (required) City: (required) State: (required) AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto Rico Zip: (required) Phone (required) What is your Industry (required) —Please choose an option—MedicalDentalEducationEnergyFinanceAutomotiveGovernmentConstructionLegalTechnologyUtilityOther Primary Contact: Your Name: (required) Your Email: (required) What AR Software do you use? NoneAtnenaHealthDentrixEaglesoftPulseQuickBooksRaintreeOther Collection Calls Service Fees: (Contingency Collections: No payment required. No Recovery-No Fees) Kinum's Commission Fees: 40% : Any Amount / Age 50% : Legal 50% : Mail Returns Service Options Transfer Preference: All accounts which remain unpaid after Collection Demands (Step 2) service can be automatically transferred to the next step, Collection Calls Service (Step 3), after waiting for 15 days. We recommend "Yes", but its your choice. NO - I will manually select and transfer accountsYES - Transfer all accounts automatically after 15 days 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 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