AMMEX Corporation Reseller Website Registration Form

Company's Legal Name *

Company's DBA/Trade Names *

Company Address *

Company Address 2

Company City *

Company State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Company Zip Code *

Entity Type * Corporation Limited Liability Company Limited Partnership Partnership Sole Proprietorship Other

State of Incorporation / Organization * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

EIN / TAX ID *

First Name *

Last Name *

Position at Company *

Email Address *

Phone Number *

1. Please identify the URL for each website where you intend to sell AMMEX products. *

2. Do you sell or intend to sell the products at any brick-and-mortar retail locations? * YesNo

Please identify the physical address for each brich-and-mortar location where you sell or intend to sell the products.

3. From which authorized distributor(s) do you purchase AMMEX products?* *

4. Do you store or intend to store your inventory of the products at a location other than the company address identified above? * YesNo

Please provide the address for all locations where your product inventory is stored or will be stored.

5. Do you intend to use any third-party fulfillment service (including any drop-shipping arrangement by an authorized distributor) to fulfill orders for the products placed through the website(s) identified in question 1 above? * YesNo

Please identify the name of the fulfillment service and describe the services provided.

Comments

By clicking submit, I agree, on behalf of Reseller, as follows:

1. Reseller acknowledges and agrees that it will abide by the Reseller Policy.
2. Reseller understands that it is strictly prohibited from using the Product brands, names, logos trademarks, service marks, trade dress, copyrights, and other intellectual property in any way other than as granted in the Reseller Policy without AMMEX’s express prior written consent in each instance.
3. Reseller affirms that the information provided in this Form is true, accurate, and current.