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Registration Form

Todays Date

Email

Dealership Name

Main Dealership Phone

Main Contact Person & Title

Direct Phone

Shipping- Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Accounting AP Contact

Accounting Email to Forward Billing Receipts

Monthly Billing Amount

Monthly Billing Date

Name of Bank

Business Name on Checking Account

Account Number

Routing Number

Billing- Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Number of ADNTV Sticks Needed

Describe Service- How Many Channels? 1 or all?

Commercials:

Factory Commercials

Factory Commercials & Dealer Commercials

Third Party Videos to add?

Additional Information

ADN.TV W9 Below, Please Print

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