Get Started with
SimplicityCollect
™
Now!
Company/Business Information
Company Name:
Contact Name:
Email:
Address:
City:
State:
Zip:
Phone:
Fax:
Timezone:
Hawaii
Alaska
Pacific
Mountain
Arizona
Central
Eastern
Guam
Central European
Virgin Islands
South African Stnd
Philippine Time
American Samoa
Atlantic Time
Singapore
Yukon Territory
NewFoundland
East Africa
Ghana
New Zealand
Billing Information
First Name:
Last Name:
Company Name:
Billing Address:
Same as Company Address Above
Address:
City:
State:
Zip:
Country:
United States
United Kingdom
Ireland
Canada
Australia
Mexico
Spain
Italy
France
Portugal
China
Russia
Singapore
Philippines
Other (Non US)
Phone:
Payment/Authorization Information
Credit Card
ACH
Credit Card Number:
Expiration Month/Year:
01
02
03
04
05
06
07
08
09
10
11
12
/
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
Card Verification (CVV):
SimplicityCollect Purchase Options
Package:
SimplicityEssentials
SimplicityBusiness
SimplicityBusiness+
Sales Rep.:
-Select One-
Christopher Jones
Cody Maschinot
Drax Amador
[None]
*
Referred by:
Startup Fee:
$1,999.00
Monthly Fee:
$749.00
Promo Code:
[Apply Promo]
Amount Due Now:
$1,999.00
SimplicityCollect Admin Information
Username:
Password:
Confirm Password:
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