Reps Wanted
Looking for Representation?
Complete our "Lines Available Ad" form below.
New ads are posted to the "members" section of our website on the Tuesday after they are received and emailed to our representative membership each week for 30 days.
Members are instructed to contact you directly if they are interested. 
*Members in good standing receive 1 free ad per membership year
**Non members will be invoiced $250 (postings are pending until invoice is paid)

Sign in to Google to save your progress. Learn more
Contact Person *
Title *
Job title of contact person listed above
Company Address (City, State, Zip) *
Best Contact Phone # *
Email *
Website (N/A if you do not have one) *
Company Description *
Tell us a little bit about your company
In Business Since? (year only) *
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
Required
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
*Invoice will be emailed within 24 hrs of receipt M-F.
**Please ad us to your safe senders list - hira@hira.org
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms