Reseller Solutions / Registration Form
We consider all Account Managers, Affiliates and/or Trade Associations without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap; or any other legally protected status.

Position Applied For:
Program(s) Marketed(1st Choice):
Program(s) Marketed(2nd Choice):
Date Of Application:

How Did You Hear About Us?
Advertisement Friend or Relative Referral
Employment Agency Internet Training Seminar
Personal Information
Company Name:
First Name:
Middle Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Telephone:
Facsimile:
Alternate Number:
E-mail:
Date of Birth:
Driver's License Number:       State Issued:
Federal Tax ID Number:
Social Security Number:  
Position Time Desired:  Full Time: Part Time:
Credit Card Processing Information
Are you currently selling Visa/ MasterCard services for another bank or ISO? 
Please list all banks and/ or ISO's you have sold for, whether the relationship is active or terminated, and if terminated, the reason.
Name of Bank and/or ISO Status Date bank relationship
began and ended
Projected average number of applications per month to be submitted to GMS:  
Terms, Conditions, and Signature

By signing below I further certify my understanding that 1) I may not represent any party or business entity products of Global, using any business name than "Company Name" listed at the top of this form; and 2) by signing the Site Inspection Form for any merchant application, I am subject to criminal penalties for false certification that I personally conduct.

I also authorize Global to ACH my residuals into my bank account in the future and I will attach a voided check to the Independent Agent Marketing Agreement. Please include a copy of your Driver's License and Social Security Card.
Print Name:   Referred By:
Date:
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