Empire Safety Council

176 Terry Road

Smithtown NY 11787

Phone: 800-246-3603 Fax: 631-360-2161

Empire Safety Council Agent/Instructor code number  __________________

Please select a discount price amount for the online course if this particular code number is

entered by a student: 

     $5 Discount    = a $15 Commission (recommended)

     $10 Discount  = a $10 Commission

     $15 Discount  = a $5 Commission

     Other amount ______________________________________

N.Y. IPIRP Reseller Agent Commission (To be applied to ALL of your Reseller-Agents):
    Reseller $7.50  -  Reseller Agent $7.50
    Reseller $10.00  -  Reseller Agent $5.00

    Reseller $5.00  -  Reseller Agent $10.00

    Other Amount ratio:____________________________________________________

Name:__________________________________________________________________  

Social Security Number / Tax ID:______________________________________________

Phone:__________________________________________________________________

Fax:____________________________________________________________________

Email Address:___________________________________________________________

Mailing Address:_________________________________________________________

To whom should the commission check be made out: _____________________________

Please sign below if you have read all of the DMV rules and regulations (CR141) of NY IPIRP. 

Document available at www.resellipirp.com and also attached to this form.  By checking this box you

agree to ALL terms and conditions of reselling the alternative method of delivery course by Empire

Safety Council and the New York State Department of Motor Vehicles.  If this signature is missing,

this form will be void.  Please sign below to acknowledge that you have read and understand

DMV-CR141 and state that you will submit all advertising to ESC for approval.

Signature:__________________  Name Printed:__________________  Date:_______________