DiamondCard Processing Print - Complete - Fax (909) 989-6343 INDEPENDENT SALES CONSULTANT Personal Information A Background Clearance is required for all independent contractor and commission only salespersons before work may begin with DiamondCard Processing. Name: _______________________________________ Email: _______________________________________ Telephone: _______________________________________ Address: _______________________________________ City: _______________________________________ State: _______________________________________ Zip: _______________________________________ Fax: _______________________________________ State: _______________________________________ Date of Birth: _______________________________________ Please list your last ten years of work history. 1. From (mm/yy): _______________________________________ To (mm/yy): _______________________________________ Company Name: _______________________________________ Address: _______________________________________ City: _______________________________________ State: _______________________________________ Zip: _______________________________________ Supervisor: _______________________________________ Annual Salary: _______________________________________ I left because: _______________________________________ Describe your position and responsibilities at this company: __________________________________________________________ __________________________________________________________ __________________________________________________________ 2. From (mm/yy): _______________________________________ To (mm/yy): _______________________________________ Company Name: _______________________________________ Address: _______________________________________ City: _______________________________________ State: _______________________________________ Zip: _______________________________________ Supervisor: _______________________________________ Annual Salary: _______________________________________ I left because: _______________________________________ Describe your position and responsibilities at this company: __________________________________________________________ __________________________________________________________ __________________________________________________________ 3. From (mm/yy): _______________________________________ To (mm/yy): _______________________________________ Company Name: _______________________________________ Address: _______________________________________ City: _______________________________________ State: _______________________________________ Zip: _______________________________________ Supervisor: _______________________________________ Annual Salary: _______________________________________ I left because: _______________________________________ Describe your position responsibilities at this company: __________________________________________________________ __________________________________________________________ __________________________________________________________ Thank you for your interest!