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Independent Sales Representative Application

APPLICANT INFORMATION: (Please type or Print Clearly Using a Dark Ball Point Pen)

Name: Are you over 18 years?

Email Address: Social Security Number: - -

Address:

City, State, Zip: Evening Phone:

Work Phone: Daytime Phone:

ASSESSMENT (Please attach Resume and Cover Letter, if applicable)

How many years of sales experience do you possess? Please indicate your desired compensation:
Less than one year
1-3 years
Please indicate your desired territories:
3-5 years
5-7 years Western United States
More than 7 years Central United States
Midwest United States
Please briefly explain your sales background. Eastern United States
International (Please indicate country)
Other (Please describe)

AUTHORIZATIONS
By signing below, I am applying to become a Power Signatures: Independent Sales Rep. I understand that I will not be treated as an employee for federal or state tax purposes. I have
carefully read Power Signatures Mobile Notary’s Independent Sales Rep Program: Independent Sales Representative Agreement Terms and Conditions and agree to abide by them.

Please fax or mail the Application Agreement to Power Signatures in order to obtain your Contractor Number. If faxed in, you must mail the original completed Application Agreement to
Copyright © 2009 Power Signatures Corporation. All rights reserved.

Power Signatures within 3 days. Power Signatures and Power Signatures Mobile Notary may be used interchangeably. This shall be enforced on an independent contractor and at-will basis.

By entering my Social Security Number (Federal Tax Identification Number/Social Insurance Number, if applicable) on this Application Agreement, I certify that this number is my correct
taxpayer identification number. I have never been a Power Signatures Independent Sales Rep., a Power Signatures employee, reseller, VAR, contractor, or a partner, shareholder,
or principal of any entity having a Power Signatures active status. I understand that any intentional misrepresentation of any information I provide on this Application Agreement may
result in action by Power Signatures, up to and including termination of this Agreement.

Make copies for yourself and send original application to:

Power Signatures Mobile Notary
Post Office Box 11068
Applicant Signature Date Torrance, California 90510-1068
(888) 678-SIGN

Power Signatures Approval Signature Date Fax to: (800) 736-3651