Agent Registration

Sales Agent Registration
For Non-Employees
This is a secure page
Please complete this form so that we may prepare the sales agent agreement.
The agreement will be sent to you via secure link for your review and digital signature.

Sales Agent Contact Information

Sales Agent Office Name *

Company Website *

* Indicates required field

Sales Office Address *

Line 1

Line 2

City

State

Zip Code

Country

Office Email *

Office Phone Number *

Office Fax Number *

Ownership Type *

Federal Tax ID/EIN or Owner's SSN *

Principal/Owner of Sales Office *

First

Last

Owner Email *

Owner Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Owner Phone Number *

Additional Information

Have you ever been convicted of a felony? *

Yes No

If yes, explain *

Have you ever been convicted of a misdemeanor? *

Yes No

If yes, explain *

Have you ever registered, been employed, or contracted with either CardConnect or First Data? *

Yes No

If yes, explain *

An affirmative answer to any of these questions may not necessarily disqualify you from consideration for registration.

I hereby acknowledge and understand that Agent's office is a separate and distinct legal entity from CardConnect, CardConnect SCal, and/or First Data. I hereby acknowledge and understand that this registration does not constitute an application for employment, and if approved, I will not be deemed an employee of CardConnect, CardConnect SCal, and/or First Data.

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