HIRA - Line
Company Name *
Contact Person *
Title
Job title of contact person listed above
Company Address (City, State, Zip) *
Best Contact Phone #
Email *
Website *
Company Description *
Tell us a little bit about your company
# of Years in Business
Product Description *
In 100 words or less, please write a description of the product/products that you are seeking representation for
Territories Open for Representation
Please mark ALL territories open for representation
Targeted Markets *
Who is your product marketed to?
Required
Commission
What commission rate do you offer?
Does this line have existing business? *
Does this line need to be pioneered? *
Payment (non HIRA member) *
I understand that payment is required and that I will be invoiced for $250
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