Simple and Effective, Secure Signup

Please be aware that the following information WILL BE PUBLICLY LISTED as your contact information for the domain registration process. As such, we require a valid address and phone number. PLEASE DO NOT PUT YOUR HOME INFORMATION HERE IF YOU DO NOT WANT IT LISTED.
First Name :	*
Last Name :	*
Company :	*
Phone :	* (example:6301112222)
Email :	*
Country :	*
Address :	*
City :	*
State/Providence :
Zip/Postal Code:	*
Marketing Software Package :
Text SMS Email Marketing Email Marketing and Text SMS
NOTE: There is one-time set up fee of $100.00 that is NOT included in these prices
BILLING INFORMATION
Billing Person's First Name :	*
Billing Person's Last Name :	*
Billing Person's Email Address :	*
Billing Person's Address Line 1 :	*
Billing Person's Address Line 2 :
Billing Person's Country :	*
Billing Person's City :	*
Billing Person's State/Providence :
Billing Person's Zip/Postal Code:	*
Billing Person's Phone :	*
PAYMENT TYPE

CREDIT CARD INFORMATION
Credit Card Type :	*
Credit Card Number :	*
Expiration Date (month/year) :	*
Security Code :	* What is this? My credit card validation code is missing or illegible.

ACCOUNT SETUP INFORMATION
Requested Domain Name :	* What is this?
Requested Business Name :	* What is this?
Account Rep Name :	* What is this?
Image Hosting:	Check this box if you wish to add Image Hosting to your Simplicity Account. Our Image Hosting system provides a simple way to make your images availble for messages that you send. This service is an addition $50. Click here for more details.
I agree to the Terms and Use of the Simplicity Marketing Software System