Empire Ambassador Royalty Report

Contact Information*
FIRST NAME LAST NAME
Company Name**
Address*
City/State/Zip
Email*
PHONE*
Today's Date**
MM slash DD slash YYYY
For the Month Ended*
MM slash DD slash YYYY
*
Date Product Delivered Quantity Cost Per Quantity Total Amount (In USD)
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Total Sales (In USD):*
10% Royalty Due To Licensor (In USD):*
Consent*
I hereby certify that the information set forth on this statement is true and complete as of the date specific above.
Signature*
Email
This field is for validation purposes and should be left unchanged.

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Date	Product Delivered	Quantity	Cost Per Quantity	Total Amount (In USD)