Rocket Receivables - Order Form

1.Questionnaire

What industry does your business belong to?

What credit cards do you accept?

Do you accept payments on your website?

Yes

2.Company Information

Purchaser's First Name {{ Reference.ErrorMessages.PurchaserFirstName }}

Purchaser's Last Name {{ Reference.ErrorMessages.PurchaserLastName }}

Purchaser's Email Address {{ Reference.ErrorMessages.PurchaserEmail }}

Company Name {{ Reference.ErrorMessages.CompanyName }}

Company Phone {{ Reference.ErrorMessages.CompanyPhone }}

Company Address {{ Reference.ErrorMessages.CompanyAddress1 }}

Attention (optional)

Zip Code {{ Reference.ErrorMessages.Zip }}

City {{ Reference.ErrorMessages.City }}

State {{ Reference.ErrorMessages.State }}

AR Software Used {{ Reference.ErrorMessages.ArSoftware }}

Market Sector {{ Reference.ErrorMessages.MarketSector }}

3.Purchase Detail

Service Type	Quantity	Cost
{{ Reference.ErrorMessages.ServiceType }}	{{ Reference.ErrorMessages.Package }} NA	{{ Purchase.Package.Value.toFixed(2) \| currency }}

SubTotal

Code:{{ Purchase.PromoCodeExtracted }}Remove

({{ Purchase.Discount | currency }})

({{ Purchase.Discount }})

Tax

Total

Quantity

Total

4.Complete Transaction

Card Number Show number {{ Reference.ErrorMessages.CardNumber }}

Expiration Date {{ Reference.ErrorMessages.CardMonth }}

Name on Card {{ Reference.ErrorMessages.CardName }}

Billing Address Same as above

Street {{ Reference.ErrorMessages.CardStreet }}

Zip Code {{ Reference.ErrorMessages.CardZip }}

City {{ Reference.ErrorMessages.CardCity }}

State {{ Reference.ErrorMessages.CardState }}

Name On Account {{ Reference.ErrorMessages.ACHName }}

Routing Number What's this? {{ Reference.ErrorMessages.ACHRNumber }}

Account Number What's this? {{ Reference.ErrorMessages.ACHNumber }}

Signer's Name {{ Reference.ErrorMessages.ACHSName }}

Signer's Phone Number {{ Reference.ErrorMessages.ACHSPhone }}

I have read and accept the Terms of Use

By checking this box I am providing my E-Signature on this Service Agreement

I will not submit debts from these Restricted Categories

Thank you for your order

Congratulations on becoming a member of the Rocket Receivables family! Before we get started, we have to prepare your account for launch. Your launch team is in the process of setting up your Username and Password. Please allow 1 business day for this setup completion. You will receive an email from us once your account is ready to go.

Questions?

Email us: help@rocketreceivables.com

Call us: 844-822-3534

You will receive an email confirmation shortly at {{ Confirmation.Email }}

Order Confirmation: {{ Confirmation.Code }}

Order Summary:

Service Type	Quantity	Cost
{{ Confirmation.ServiceType }}	{{ Confirmation.Package }}	{{ Confirmation.PackageValue \| currency }}

SubTotal

Code:{{ Confirmation.PromoCode }}

({{ Confirmation.DiscountValue | currency }})

Tax

Total