Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Billing Information Business Name *Applicant's Name *FirstLastAuthorized Payment Types (check all that apply) Authorized Payment Types *ACH**Credit Card** ACH payments earn an extra 1% discount Primary Form of Payment (check one) Primary Form of Payment *ACH**Credit Card** A Credit Term Application must be filled out and approval must be successful before Audio Dynamics will process an order via ACH. Also, a valid credit card must be on file and be used on a complete order before ACH can be implemented for future orders. ACH payments earn an extra 1% discount. Direct Payment via ACH is the transfer of funds from a business’ bank account for the purpose of making a payment. I (we) authorize Audio Dynamics to electronically debit my (our) account (and, if necessary, electronically credit my (our) account to correct erroneous debits*), and/or charge my (our) credit/debit card. Amount of debit(s) or method of determining amount of debit(s) [or specify range of acceptable dollar amounts authorized]: By verbal agreement. Date(s) and/or frequency of debit(s): By verbal agreement. I (we) understand that this authorization will remain in full force and effect until I (we) notify Audio Dynamics in writing that I (we) wish to revoke this authorization. I (we) understand that it requires at least 5 days prior notice in order to cancel this authorization.** Name on Account Name on Account *Account Type Account Type *Business CheckingBusiness SavingsPersonal CheckingPersonal SavingsRouting Number Routing Number *Account Number Account Number *Bank Phone Number Bank Phone Number *Credit Card Payment Information Name on Card Name on Card *Card Number Card Number *Expiration Date Expiration Month *010203040506070809101112Expiration Year *20242025202620272028202920302031203220332034203520362037203820392040Code on Back of Card Code on Back of Card *Billing Zip Code Billing Zip Code *I (we) authorize Audio Dynamics to electronically debit my (our) account (and, if necessary, electronically credit my (our) account to correct erroneous debits*), and/or charge my (our) credit/debit card. Amount of debit(s) or method of determining amount of debit(s) [or specify range of acceptable dollar amounts authorized]: By verbal agreement. Date(s) and/or frequency of debit(s): By verbal agreement. I (we) understand that this authorization will remain in full force and effect until I (we) notify Audio Dynamics in writing that I (we) wish to revoke this authorization. I (we) understand that it requires at least 5 days prior notice in order to cancel this authorization.** Driver License * Click or drag a file to this area to upload. Signature Clear Signature Authorized Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920* The NACHA Operating Rules do not require the consumer’s express authorization to initiate Reversing Entries to correct erroneous transactions. ** Written debit authorizations must provide that the Receiver may revoke the authorization only by notifying the Originator in the time and manner stated in the authorization. The reference to notification should be filled with a statement of the time and manner that notification must be given in order to provide company a reasonable opportunity to act on it Submit
