Application for Enrollment
First Merchant Payment Systems is an equal opportunity employer and a drug free workplace.
1400 Colonial Blvd, Suite 256 - Fort Myers, FL 33907

Personal Information
Name (Last, First, Middle) , ,
Address
City , State Zip
Contact Phone                        Date You Can Start
EMail
Industry Experience Information (If Applicable)
Average Deals signed per month?
Number of pieces of equipment sold per month?
Type (industry specific) of merchants signed?
Average profit margin per deal (if known)?
Average annual processing volume per deal?
Do you currently recieve residual payments?   If Yes, Amount per month:
Work History
(Give information about your last 3 jobs, starting with the most recent)
Employer 1
Current Employer Dates Employed
City & State
Title/Duties
Employer 2
Previous Employer Dates Employed
City & State
Title/Duties
Employer 3
Previous Employer Dates Employed
City & State
Title/Duties