Customer Purchase Order And Payment Authorization Form

Instructions: (See video below)

Customer is approved for a loan through Flexxbuy and agrees to accept one of the offers provided.
Business/Merchant completes this form.
Customer is instantly emailed a purchase/payment authorization agreement to complete and esign. Note: Bank account name, routing and account number will need to be entered in by customer.
Initial deposit is processed. If by Flexxbuy, a check draft will be created and emailed to your business for deposit.
Flexxbuy is notified of the loan funding and processes a check draft to be deposited by your business.
After payment clears (typically 2 to 3 business days), business/merchant release the product or provide the service to the customer.

Customer Purchase Order And Payment Authorization Form

This form will generate an invoice/payment authorization for the customer to esign. It is to be noted, that no payment can be processed by Flexxbuy unless the customer completes the authorization by submitting bank account information and esigns the document. You will notified when this has been completed.

Customer Information

Customer Name(Required)

First Last

Street Address(Required)

Street Address 2

City(Required)

State(Required)

Zip Code(Required)

Email Address(Required)

Contact Phone Number(Required)

Merchant/Business Information

Business Name(Required)

Name Of Business As It Is To Appear On The Payment, If Different

Business Street Address(Required)

Business Street Address 2

Business City(Required)

Business State(Required)

Business Zip Code(Required)

Business Contact Name(Required)

First Last

Business Contact Email Address(Required)

Business Contact Phone(Required)

Transaction Information

Description of Product or Service Sold(Required)

Final Sale Amount (including Sales Tax, S&H, etc)(Required)

Amount Of Initial Deposit Collected From Customer(Required)

Enter $0 if no deposit

Customer Deposit Processed By:(Required)

Note: If Flexxbuy processes the initial deposit payment, it will create a check draft from the customer's bank account and email it to merchant for deposit on the date indicated.

If your business collects its own deposit payment, you determine the payment method between you and your customer.

Date Of Initial Deposit(Required)

Enter today's date if payment is to be processed immediately

Amount Of Any Other Deductions, Rebates, Etc.(Required)

Enter $0 if none.

Final Amount Due Your Business Upon Funding Of Loan(Required)

The Sale Amount Less All Deposits And Deductions Made Prior To Final Payment. This will be populated automatically.

Final Payment Processed By:(Required)

Note: If Flexxbuy processes the final payment, it will create a check draft from the customer's bank account and email it to merchant for deposit upon funding notification.

If your business collects its own final payment, you determine the payment method between you and your customer.

I acknowledge the following:

* I have completed this form accurately, to the best of my knowledge;
* The authorization generated by this form will be completed and signed by my customer or the individual that is securing the financing on behalf of my customer, only;
* I am responsible for notifying Flexxbuy of any changes to the terms outlined on this form;
*All payments processed by Flexxbuy to the business are generated from the customer's bank and can not be guaranteed by Flexxbuy;
*Flexxbuy is unable to process any payments unless it receives the completed and signed authorization generated by this form;
* Any product or service delivered or produced prior to the collection and clearance of all payments due is risky and not considered wise business practice.

Sign Here(Required)