Registration Application

Sales Partner Name:

Type of Business: Agent☐Sole Prop.☐ Partnership Corp.☐

Company Registration #: (If applicable) National Insurance #:

Name of Principal(s):

Business Street Address:

City/Town: County/Country: Postal Code

☐ Check this box if the above address is NOT physical location (example: Postal Box)

Phone: Fax:

Mobile: Email:

Personal Contact
Home Street Address:

City/Town: County/Country: Postal Code:

Phone:

The following information is held confidential, but is required:

Last Employer Name: Last Employer Contact:

Reference Name: Phone:

Previous Processor: Years in Industry:

Projected Number of Merchant Applications per Month:

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6

eMerchant Broker Rev102015