Amsoil Dealer Application

AMSOIL INC.
AMSOIL BUILDING l SUPERIOR, WI 54880
REGISTRATION APPLICATION (for the United States and Puerto Rico)
Complete Parts A and B, then select and complete Option #1 (Preferred Customer) or Option #2 (Dealership).

Part A SPONSOR INFORMATION (To be completed by Sponsor)
SPONSOR Z.O. NO.: 1528991 NAME: (last, first ) JECZALIK TED

Part B APPLICANT INFORMATION (To be completed by Preferred Customer or Dealer)
NAME (Last, First, Initial)
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SPOUSE (First, Initial) PHONE NO.
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STREET ADDRESS
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CITY STATE ZIP CODE
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E-MAIL ADDRESS
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Option #1 ___ CHECK HERE FOR PREFERRED CUSTOMER OPTION (No signature required for Option #1)
As a Preferred Customer you are entitled to purchase AMSOIL products at wholesale prices. You are not signing up for the
business opportunity at this time, but will have the ability to upgrade your membership status at any time in order to sell AMSOIL products, establish commercial and retail accounts and earn commissions.
_____ $10 for a six-month trial Preferred Customer membership and starter Kit.
_____ $20 for a twelve-month regular Preferred Customer membership Starter Kit.
Mail in this application with a check or fax to 715-392-5225 or call 800-777-7094 for
payment with Visa, MasterCard or Discover Card. Allow up to five business days.
Enclosed Check #____ for $______ , Visa/Discover/MasterCard #_________________ Expiration Date ____/______/_____

Option #2____ CHECK HERE FOR DEALERSHIP OPTION (Dealership Option Application must be mailed to: AMSOIL INC.
AMSOIL BUILDING l, SUPERIOR, WI 54880. DO NOT FAX.)
As an Amsoil Dealer you are entitled to sell AMSOIL products, establish commercial and retail accounts and earn commissions.
SOCIAL SECURITY NO. SPOUSE'S SOCIAL SECURITY NO.       DATE OF BIRTH
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OCCUPATION                                                                   RESALE TAX NO.
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THIS AMSOIL BUSINESS SHALL BE OWNED AS: ___ A SOLE PROPRIETOR, ____ HUSBAND/WIFE JOINTLY
(Signed Uniform Sales and Use Tax Certificate Must Be Attached if Applicable.)
SELECT ONE: (costs include tax, freight, and handlling)
_____ $15 for a six-month trial Dealer registration and Starter Kit.
_____ $30 for a twelve-month regular registration and Starter Kit.
_____ $65 for a twelve-month registration and Business Manual.
OPTIONAL: _____ $30 for a G-1312 Literature Pack
Starter Kits, Business Manuals, and Literature Packs will be sent to you by AMSOIL INC.
Enclosed Check #________ for $_______ , Visa/Discover/MasterCard #_____________________ , Expiration Date ____/_____/____

As a new Dealer, I understand and agree that:
1. I am of the age of majority in the state in which I reside when I apply for appointment
as a Dealer of AMSOIL products. Upon acceptance of this application by AMSOIL, I will
be an independent Dealer responsible for my own business and not an employee of
AMSOIL INC. I will not be treated as an employee in regard to any laws covering
employees including but not limited to the Federal Insurance Contribution Act, the Social
Security Act, the Federal Unemployment Tax Act and income tax withholding at source.
It is my responsibility to pay self-employment, state and federal income taxes as
required by law.
2. The term of the AMSOIL Dealership registration is one year. I understand that the
registration fee entitles me to indemnification in the event of damages resulting from the
failure of AMSOIL products to perform properly when used according to the
manufacturer's recommendations. It also entitles me to a subscription to ACTION
NEWS, the AMSOIL official company publication. AMSOIL Dealers who wish to continue
their Dealerships must apply to renew their Dealership status.
3. This agreement may be cancelled at any time. Upon written notification of
cancellation or termination, AMSOIL INC. will repurchase inventory and refund fees in
accordance with the policies stated in the AMSOIL MULTI-LEVEL MARKETING SALES
PLAN.

4. No purchase is necessary to become an AMSOIL Dealer other than the
purchase of a Business Manual which is sold at company cost.
5. In a separate attachment hereto, I have described any litigation in which I am
presently involved or previously have been involved.
6. Upon receipt of the Business Manual, I will carefully review the policies as set
forth in the AMSOIL MULTI-LEVEL MARKETING SALES PLAN and acknowledge
that they are incorporated as part of this agreement in their present form and as
modified from time to time by AMSOIL. AMSOIL, at its discretion, with notification
to the Dealers may amend the MULTI-LEVEL MARKETING SALES PLAN and terms
of this agreement.
7. This Dealership may be revoked if I fail to comply with the policies of the
AMSOIL MULTI-LEVEL MARKETING SALES PLAN.
8. AMSOIL reserves the right to accept or reject any application.
9. This Sales Plan shall be governed by the laws of the State of Delaware.

X________________________________________ X____________________________________
Applicant's Signature Date Spouse's Signature (if held jointly)

G-18C

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