Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Billing Information Dealer Status *Current DealerNew DealerBusiness Name *Applicant's Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness PhoneCell PhoneEmail *Website / URLTax ID # *Resale # *A copy of Tax ID and Reseller Permit (where applicable for your state) will need to be included with this application. Picture of Tax ID / Reseller Permit Click or drag a file to this area to upload. Shipping Address *Same as BillingAlternate Address(Alternate) Business Name *(Alternate) Name *FirstLast(Alternate) Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAuthorized 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** ACH payments earn an extra 1% discount Direct ACH Payment Information (Preferred) – Earns 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. 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 Date *Code on Back of Card Code on Back of Card *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. SignatureClear SignatureAuthorized Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920* 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