Wholesale: Captivated Order Form

Wholesale Site License includes:
• Up to 5 Text Lines included (10DLC) - Toll free is a separate line and billed at a different rate)
• 1000 Complimentary Text messages are included (then 1.5 cents per msg)
• 250 Complimentary Voice minutes (then 1.5 cents per minute)
• 250 Complimentary Video Chat minutes (then 1.5 cents per minute)
• All BASIC features included – see https://captivated.works/pricing/
• Includes text line activation and 10DLC registration for 1 brand**
• Includes online setup & training
• In-App Technical Support

* Additional brands/branches/locations may require a separate account and text line(s)

Coupon or referral code

Customer Information

First Name *

Last Name *

Email Address *

Phone

Organization

Billing Information

All transactions are secure and encrypted.

First Name on Account *

Last Name on Account *

Card Number *

CVV *

Expiration Month *

Expiration Year *

Billing Address

Address 1 *

Address 2

Billing Country *

Billing City *

Billing State *

Billing ZIP Code *

Additional Information

EIN (business tax ID) if applicable

Key Contact for onboarding

Key Contact Email

Business Website Address - URL

I accept the Terms and Conditions

Setup Fee	$150.00
Recurring Fee (every 1 month)	$95.00
Today's Total	$245.00
then $95.00 at first renewal on 12 Jun 2025