Brand Ambassador Application - Trucking Industry Brand Rep

First & Last Name *

Company Name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

ONLINE PRESENCE

Instagram Handle

Twitter Handle

Facebook Profile/Page (Must include https://)

YouTube Channel (Must include https://)

LinkedIn (Must include https://)

YOUR TRUCK INFORMATION

Do you have a truck? *

What model? *

If other, please advise *

Do you have a show truck? *

What shows will you be attending in the near future? *

If other, please advise *

Press/Features?

Upload a Picture of Your Truck

Click or drag files to this area to upload. You can upload up to 3 files.

PREFERRED COUPON CODE

Unique coupon code you would like to share with your followers *

CREDIT CARD INFORMATION

We will run an authorization on your credit card for $257.75. This is just to ensure that you will deliver on your end of our agreement once we ship you the Leak Defender free of charge. Once your term is completed and you have provided the services outlined in the terms of service, you will not be charged a penny.

Credit Card Number *

Expiration Date *

Cardholder Name *

Card Security Code *

Is your billing address the same as above? *

Yes
No

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

SIGNATURE & TERMS

Agree to Terms *

I acknowledge and agree to the following terms.

Please read carefully the following terms of service. This is a contract between Heavy Truck Solutions LLC (“HTS” or “We” or “Our” or “Us”) and you. You acknowledge that you have read and understood these terms. Further, if you accept our offer for a free Leak Defender® and/or promote our product online, you accept and agree to be legally bound by these terms.

By signing below, you:

1. Agree to committing to a 3-month term during which you will provide 2 high quality, unique and varied photo and/or video social media posts each month. All photo and/or video posts will properly tag our social media page on that particular network as well as be accompanied by the hashtag #leakdefender and #heavytrucksolutions.

2. Authorize HTS permission to publicly display, copy, reproduce and use the photographs and videos related to our product(s) that are shared during your term in any form or media, whether now known or hereafter devised, for any and all editorial and related promotional purposes without making payment or other remuneration to yourself or any third party.

3. Represent and warrant that the photos and/or videos will be your original work, or will be properly licensed by yourself and will not violate the copyright or any other personal or property right of any third party, and you will have obtained any and all releases and permissions necessary prior to posting for HTS to publicly display, copy, reproduce and use the photos and/or videos as described above.

4. Authorize HTS to edit, crop or otherwise alter any photos and/or videos related to our product(s) as we choose.

5. Agree, should you not follow these terms of service, to forfeit your right to receive compensation for your referral sales and will return the Leak Defender® that was given to you.

6. Authorize, should you not follow these terms of service and fail to return the Leak Defender to HTS, Us to charge your credit card $257.75

Electronic Signature *

Your signature indicates that you have read, understand, and agree with the terms stated above.

Date *

BRAND REP APPLICATION

ONLINE PRESENCE

YOUR TRUCK INFORMATION

PREFERRED COUPON CODE

CREDIT CARD INFORMATION

SIGNATURE & TERMS

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