Date ___________________  Dealer Name   ______Glen & Karen Blomgren ___________________
Dealer Number _____1200283 _________________________________________________________
Commercial  Account Name ___________________________________________________________
Commercial Account Number __________________________________________________________
Order Number(s) and Dates ____________________________________________________________
Total Gallons Ordered __________________________ Number of Kits (1 per 10 gallons) ________
Kit Options (Check One)            Postage Due        Postage Prepaid        UPS Prepaid               
U.S.                                          ___ $13.91        ____ $16.01            ____ $21.79          
Canada                                   ____$23.05         ____ $N/A              ____ $N/A
Number of Kits _________________________  Bill to Dealer/Account #  _______________________
Price per  Kit $ _________________________   Ship to ______________________________________
Total ___________________________________  Address _____________________________________
Tax ____________________________________  City _________________________________________
Amount Due $ __________________________  State ____________  Zip _______________________
Method of Payment (check one)        ___ Check        ___ Credit Card        ___ PO #Check # ______
Amount $ _____________________________________________Visa/MC ________________________
Security Code ________ Exp. Date _______Credit Card Billing Address _______________________
Credit (approved accounts only) __________________________________________________________

Submit to:AMSOIL INC.
Attn:Technical Services
One AMSOIL Center
Superior, WI 54880
Fax (715) 392-3097                                                                                                                     8/22