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Company/Business Information
Company Name:  
Contact Name:  
Email:  
Address:  
City:
State:
Zip:
Phone:  
Fax:
Timezone:
Billing Information
First Name:  
Last Name:  
Company Name:
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State:  
Zip:  
Country:
Phone:  
Payment/Authorization Information
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Card Verification (CVV):  
Only your monthly subscription amount and start-up fee will be processed via this payment method. Payment processing fees are collected separately. More information will be provided in your onboarding information.
SimplicityCollect Purchase Options
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Startup Fee: $2,999.00
Monthly Subscription Fee: $1,999.00
Payment Processing Fee: Based on Volume
Promo Code: [Apply Promo]
Amount Due Now: $2,999.00
SimplicityCollect Admin Information
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