Reseller Account Application Form

or call 1(800)408-7101 x103 (Office Hours 10am - 5pm EST)














Please check all that apply









Required for ALL accounts

Actuator Systems, LLC ("AS") has permission to charge the following credit card for all orders we place with AS if our account is a Cash/Credit Card Account. If our account is a Net 30 account, AS has premission to charge the following credit card for all payments that are more than 30 days past due.









  Please enter the expiration date as MM/YYYY








By clicking submit you agree not to advertise any products we provide below the indicated MAP pricing.