Fill-Rite Company Authorized Reseller Website Registration Form

Company's Legal Name

Company's DBA/Trade Names (If Any)

Company Address

Company Address 2

Company City

Company State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Company Zip Code

Company Email Address

Company Phone Number

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

State of Incorporation/Organization AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

EIN/Tax ID

Primary Contact First Name

Primary Contact Last Name

Primary Contact Position at Company

Primary Contact Email Address

Primary Contact Phone Number

1. Do you sell or intend to sell Fill-Rite and/or Sotera products at any brick-and-mortar selling locations? Yes No

Please identify the physical address for each brick-and-mortar location where you sell or intend to sell Fill-Rite and/or Sotera products.

2. Please identify the URL for each website where you intend to sell Fill-Rite and/or Sotera products. Please review the restrictions on online sales in the Authorized Reseller Policy carefully. Please note that you are only permitted to sell the Fill-Rite or Sotera products on “Permissible Public Websites,” as defined in the Authorized Reseller Policy. Consent to sell Fill-Rite and/or Sotera products on online marketplaces is not granted through this website registration process.

3. From which authorized distributor(s) do you purchase Fill-Rite and/or Sotera products?

4. Do you store or intend to store your inventory of Fill-Rite and/or Sotera products at a location other than the company address identified above? Yes No

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

5. Do you intend to use any third-party fulfillment service (including drop-shipment by an authorized distributor) to fulfill orders for Fill-Rite and/or Sotera products placed through the website(s) identified in question 2 above? Yes No

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

LEGAL AGREEMENT: By checking this box, I agree, on behalf of Reseller, as follows: I agree 1. Reseller acknowledges and agrees that it will abide by the Fill-Rite Company Authorized Reseller Policy for the United States . 2. Reseller understands that it is strictly prohibited from using Fill-Rite’s brands, names, logos, trademarks, service marks, trade dress, copyrights, and other intellectual property in any way other than as granted in the Authorized Reseller Policy without Fill-Rite’s express prior written consent. 3. Reseller affirms that the information provided in this Form is true, accurate, and current.

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