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Application
SAM’S 21 Independent Sales Agent/Affiliate Application
Please complete this application to be considered for the SAM’S 21 Independent Sales Agent/Affiliate program.
Personal Information
Firt Name
Last Name
Address
City
State
Zip Code
Phone
Email
Are you authorized to work in the United States?
Yes
No
Employment History
Please list your work experience for the past 5 years.
Employer 1:
Employer Name
Position
Start Date
End Date
Responsibilities
Reason for leaving
Employer 2:
Employer Name
Position
Start Date
End Date
Responsibilities
Reason for leaving
Employer 3:
Employer Name
Position
Start Date
End Date
Responsibilities
Reason for leaving
Why are you interested in becoming a SAM'S 21 Independent Agent/Affiliate?
What qualifications or skills make you a strong candidate for this position?
By signing, I certify that the information provided in this application is true and accurate. I understand that any false or misleading information may result in the termination of my Independent Agent/Affiliate Application and all related agreements.
Signature
Date
Submit