First Name Last name

Home Address City

State Zip Code Telephone -

Social Sec. Num

Work/ Sales experience

From:	To:	Company Name	Position	Salary	Reason for Leaving

List any special skills, foreign languages, or educational background:

Why do you believe you would be a good candidate for an independent sales representative for USB Merchant Services:

I authorize investigation of all statements contained on this application. I am enclosing a check or money order payable to Merchant Card Services for registration as and Independent Sales Representative (ISR) in the amount of $195.00. I will receive all required documentation, literature, training materials, merchant applications, and ongoing sales support. I understand that my earnings will be commission only and be paid without withholding of state or federal taxes. I will be responsible for reporting such earnings. Any residual earnings will be paid by corporate check and subject to withholdings. I understand that fees submitted with this application will be refunded only if this application is declined by Merchant Card Services.

Signature:___________________________________________ Date: _____________________

Please Print This Page, sign & date it, and mail along with check or money order AND a copy of your Driver's License and social security card to :