CivicPlus Rep Name:

CivicPlus Rep Email:

CivicPlus Rep Phone:

Agency Account Name: *

Department:

Website:

Contact First Name: *

Contact Last Name: *

Contact Title: *

Contact Phone: *

Contact Email: *

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Current CivicPlus Customer? Yes No

Braintree OR End Of Life (EOL) Migration Yes

Select Payment Option(s): Credit CardACH

Select Fee Option: Agency Absorbed Service (Convenience) Fee

Which CivicPlus solution(s) will you configure payments with? * Web CentralWeb OpenCommunity DevelopmentRecreation ManagementProcess AutomationNextRequest

Planned Go Live Date *

Deadline for Testing Credentials *

Any additional notes for the Forte team?

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