AXIS Independent Representative Agreement

For Applicants Located Near Gautier, MS Only. This is An INSIDE Sales Position. This Position Requires that you Have Your OWN LAPTOP. You Are Applying for a Call Center / Telemarketing Position by Filling Out this Application. Offered by Completing this Agreement and agreeing to work with AxisNewTech / Roy Rogers Communications / AT&T DIRECTV, Viasat Satellite and various Merchant Processing and Finance Companies. By Checking the Box Below - You State That: I also Authorize AT&T DIRECTV, AxisNewTech and or Roy Rogers Communications to Conduct a background check in connection with my employment now and at anytime while contracted or employed. Click the Small Box at the Left Below this paragraph to indicate you have read and understand before continuing. *

Check this Box to Continue

Date: *

Your First Name: *

Your Last Name: *

Email Address: *

How Did You Hear About us?: *

Date of Birth: (Must be 18 years to continue) *

Place of Birth: (City & State) *

Social Security Number: *

Residence Address (Number. street and APT Number (if Necessary) *

Residence City *

Residence State *

Residence Zip Code *

Main Business Phone Number To Reach You At: *

Alternate Telephone Number:

Were you born in the US? *

If no, are you residing in the US legally?

If You are in the U.S. Illegally Immediately Stop This Application. You Cannot Be Hired. Contact Hr@AxisAgi.com if you have questions.

COMMISSIONS ARE TO BE PAID (Please check one): *

Yourself Your Agency/Company

IF COMMISSIONS ARE TO BE PAID to My Company:

Enter EIN Number

Do You Have a State Issued Drivers License Number: *

Select Yes or No

Your State Issued Drivers License Number: *

Expiration Date: *

Suspended? *

Select Yes or No

If yes, explain

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Printed Legal Name *

By Signing You Acknowledge That this is the Same as a Wet Signature and is legally binding: *

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