Merchant Business Services

131 Crown Point Circle

Longwood Florida 32779

Independent Contractor Registration Form

Must be completed by all persons marketing products/services offered by Merchant Business Solutions
LLC Referred by: _________________________________________
Company d/b/a Name (if applicable): ___________________________________________________
Contractor Name: ___________________________________________________________________
Home Address: _____________________________________________________________________
City: ____________________________________________State: ___________ Zip: ____ _______
Home Phone #: _____________________Cell Phone #: ______________________________
Social Security #:_____________________________________
Date of Birth:_____________________
e-Mail Address:_________________________________________________________________
Sales Experience (years): ___________________________
Average # of deals per month: ______________
Previous Bankcard Experience (Y/N): _____
PAYMENT INFORMATION

Processors: ___________________

(Must Complete ACH Authorization Form)

Pay to: PREPAID/DEBIT CARD

Checking Account:

Savings Account

e-WALLET

Independent Contractor Acceptance

By signing below Independent Contractor indicates all the information supplied is accurate and truthful
to the best of their knowledge. Additionally, Independent Contractor authorizes Optimum Payment
Solutions and/or their processors/vendors to investigate/verify their information including the use of
credit bureaus.
I Accept the Terms and Conditions of the Independent Contractor Agreement.
Signature: ______________________________________________________ Date: NOTE: ATTACH A
COPY OF CURRENT DRIVERS LICENSE