Kimber Counter Staff Sales Incentive Program

Model Selection & Pricing Information

Model Item Code:

Model Description:

Points redeemed (based on qualifying sales):

Sales Associate Information

Full name:

Address: Phone #:

City/State/Zip: Email:

Shipping Address — Must be shipped to Master Dealer location

Store name: FFL#:

Address: Phone #:

City/State/Zip:

Any participant who submits Kimber Points for rewards with an individual or combined value of $600 or more must complete and submit an IRS Form W-9. This must be included with your submission.

Under penalties of perjury, I certify that:

>> I am not subject to backup withholding because 1.) I am exempt from backup withholding or 2.) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or 3.) the IRS has notified me that I am no longer subject to backup withholding.

>> All information provided to Kimber by me, and all statements contained herein are true and accurate, and I have and will comply with all applicable laws and regulations, including but not limited to the Gun Control Act of 1968 (“GCA”), The Arms Export Control Act (“AECA”), and the Export Administration Regulations (“EAR”). In addition, I am a US Person as such term is defined in 22 C.F.R. § 120.15.

By selecting this checkbox, I hereby confirm that I have read and agree to the above statements. I have also read and agree to the Instructions outlined on page 5 as well as the Terms and Conditions on page 9 of the Counter Staff Sales Incentive Program.

Please see your sales representative to obtain a copy if needed.

Sales Verification Form

Serial #	Model Name	Date Sold	Points Earned*
Record each new Kimber® K6xs revolver, R7 Mako pistol, 1911 pistol, KDS9c pistol, Micro/ Micro 9™ pistol, or K6s™ revolver you sell on the chart above.

Upload Files

Sales Receipts *

Sales Verification Form *

Application Form * You must submit a signed copy of the Application Form (page 8). Please see your sales representative to obtain a copy if needed.

Pay Stub *

IRS Form W-9 *If redemption request is over the value of $600