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Account Set Up

Account Set Up

Company/Organization Name

Street Address

City
State
Zip Code

Primary Contact Information

Primary Contact's Name
Primary Contact's Email Address
Primary Contact's Phone

Accounting Contact Information (if different than above)

Billing Contact's Name
Billing Contact's Email
Billing Contact's Phone

IT Contact Information

If your company/organization has a technical contact that assists with domain set up, platform integrations, or the like, please provide their contact info.

IT Contact's Name
IT Contact's Email
IT Contact's Phone

Other Contacts with Access to the Website

Please provide names and email addresses for any other people in your organization who will need administrative access to the website.

Name
Email Address

Name
Email Address

Name
Email Address

Name
Email Address

Name
Email Address

Credit card Information

Name on Credit Card
Credit Card #
Expiration Date

Security Code
Zip Code Associated with CC

Please check this box to confirm automatic billing of your credit card.I authorize Captiva Marketing to charge my credit card on a monthly basis.

Terms of Use

Please read the following Terms of Use and then check box confirming your agreement to these terms.Agree

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