Outside Rep Application Form
or call 1(800)408-7101 x103

Company Information
Credit Card Information (Required for Samples)

Contact Name:
Company:
Address:
Address 2:
City:
ZIP: State:
Day Telephone:
Fax:
E-mail:^*
Website:

Actuator Systems, LLC ("AS") has permission to charge the following credit card for any unreturned samples provided to outside representative. Outside rep must return any samples upon notification by AS or termination of the representation agreement by either party. AS must receive the samples within 14 days of such notification or termination. AS is authorized to charge the credit card for the shipping of the samples to the outside representative.

Visa
MasterCard
American Express
Discover

Name on Card:
Card #:
Expiration Date: Please enter the expiration date as MM/YYYY
Security #:
Billing Address:
Billing Address 2:
City:
ZIP: State:

By clicking submit you agree to the terms and conditions herein and attest that the information provided is accurate and factual.

RUMS Software Upgrade

New Generation of Fingerprint Locks

Outside Rep Application Form
or call 1(800)408-7101 x103

RUMS Software Upgrade

New Generation of Fingerprint Locks

Outside Rep Application Formor call 1(800)408-7101 x103

Outside Rep Application Form
or call 1(800)408-7101 x103