Sales Agents Application Form

SALES AGENTS APPLICATION FORM

Applicant Identification

Entity Information and Licenses

Entity Type: Individual Partnership Corporation LLC Other

Representative Experience and Territory

Years engaged in sales or representation of similar products:

Representative Product / Service Listing

List products or services you currently represent or propose to represent for the Principal. Include proposed commission terms for each line.

Commission Structure and Payment Preferences

Preferred payment method: ACH / Bank Transfer Check Wire Transfer

References

Provide three professional references who can confirm sales performance and character.

Background, Compliance and Insurance

Have you or any entity you control been convicted of a felony or crime involving fraud or financial misconduct? Yes No

Have you or your business been subject to bankruptcy, receivership, or insolvency proceedings in the last 10 years? Yes No

Do you maintain professional liability or errors & omissions insurance covering sales activities? Yes No

Declarations, Authorizations and Certifications

By signing below the Applicant certifies, represents and warrants that all information provided in this application is true, complete and correct to the best of Applicant's knowledge. Applicant authorizes the Principal to verify any information provided, including credit, background, licensing and employment history, and to contact references and insurers as necessary to evaluate this application. Applicant agrees to promptly notify the Principal of any material change in circumstances affecting the information provided.

Applicant agrees that any appointment as a sales agent will be subject to a written agency agreement setting forth commission calculations, payment timing, territorial limitations, confidentiality obligations and termination rights. Until such an agreement is executed, no commissions are owed and no authority to act on behalf of the Principal is granted. Applicant acknowledges that the Principal may withhold commissions for returned goods, chargebacks, or unapplied credits as set forth in any subsequent agency agreement.

Applicant further agrees to comply with all applicable laws, regulations and Principal policies when soliciting sales and shall not make representations or guarantees beyond those expressly authorized in writing by the Principal. Applicant will indemnify and hold harmless the Principal from third-party claims resulting from Applicant's negligent, willful or unlawful acts in performance of sales activities.

I affirm the information provided in this application is true and complete. I authorize background, credit and reference checks as necessary for evaluation. If appointed I will execute the Principal's standard agency agreement and comply with its terms.

Limitation of Liability and Governing Law

The Principal and Applicant agree that any resulting agency agreement will contain a limitation of liability provision capping direct damages to the amount of commissions paid in the twelve (12) months preceding a claim, and excluding consequential, incidental and punitive damages to the fullest extent permitted by law. The parties further agree that any dispute arising out of or relating to this application or any subsequent agency agreement shall be governed by the substantive laws of the state selected by the Principal in its written agreement, without regard to choice-of-law principles.

Signature and Authorization

The undersigned warrants that he or she is authorized to submit this application on behalf of the Applicant identified above and understands that submission of this application does not constitute an appointment or promise of appointment as a sales agent. Applicant agrees that any false statement or material omission may be grounds for denial of appointment or termination of any subsequent agency relationship.

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