ALLIED MEMBERSHIP APPLICATION

Allied membership shall be available to manufacturers in the health care industry who currently, or who have announced plans to, market via independent contractor sales representatives. Policies governing the participation of Allied members shall be determined by the Board of Directors of the Association.

Name of Company:
Company Delegate to HIRA:
 Title:
Address:
State or Province:
City:
Zip:
Phone:
Registered Trade Name:
Fax:
E-mail:
Web Site:
# of Years in Business:
Individual Ownership
Partnership
Corporation

Company Officers: Those Involved in Sales & Marketing
Name:
 Title:
Name:
 Title:
Name:
 Title:
Products Manufactured:

Please mark any of the following markets into which your product(s) are sold:
Hospitals Labs
Drug Wholesalers Purchasing
Nursing Homes X-ray
OEM Sub Acute Care
Physicians/Alternate Care Dental
Industrial Rehab
Home Care Veterinary
Capital Equipment

Have you used Independent Reps in the past? Yes No

Do you now use Independent Reps? Yes No

Indicate States or Provinces, if any, serviced by your own direct personnel:

Is this because you:

States or Provinces currently open for representation:

SPONSOR: If a HIRA member is sponsoring your Application, please indicate who below:
Name:
Firm Name:

Allied Membership is $495.00 per year, please contact the HIRA Office at (800) 777-4472 to pay by credit card

Health Industry Representatives Association
7315 East 5th Avenue
Denver CO 80230

Phone: (303) 756-8115
FAX: (303) 341-0282
E-mail:
http://www.hira.org

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