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
/
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
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
Package:
Essential
Scale
Expansion
Enterprise
Sales Rep.:
-Select One-
Christopher Jones
Ethan Lee
[None]
*
Referred by:
Startup Fee:
$1,999.00
Monthly Subscription Fee:
$999.00
Promo Code:
[Apply Promo]
Amount Due Now:
$1,999.00
SimplicityCollect Admin Information
Username:
Password:
Confirm Password:
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