Empire Safety Council

176 Terry Road

Smithtown NY 11787

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

ESC Reseller code number:________________

Reseller Agent code number:  ______________

Name (of Reseller Agent):_____________________________________________________________  

Phone:_____________________________________________________________________________

Fax:_______________________________________________________________________________

Email Address:______________________________________________________________________

Mailing Address:_____________________________________________________________________

Social Security Number/ Tax ID:________________________________________________________

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:______________