Representative Membership Application

Membership in this Association shall be composed of those firms, corporations, partnerships or individuals which have operated for more than one (1) year. If you do not satisfy that criteria, we will accept one (1) year’s experience in the healthcare field plus sponsorship by three (3) current HIRA members. In addition to the experience and sponsorships, the applicant must be performing the function of an independent contractor sales representative for two (2) or more principals who manufacture healthcare products. He/She must not have engaged, and agree not to engage, in any activity prohibited by the association’s Code of Ethics.

Firm Name:
Name of Firm's Delegate to Assn.:
Title:
Nickname for Conference Badge:
Delegate's Spouse's Name:
Mailing Address:
E-mail Address:
Web Site:
City:
State or Province:
Zip Code:
Telephone Numbers:
Business:
FAX:
Home:
Year Firm Founded:
Number of Salespeople:
Number of Inside Employees:
Principals of the Firm:

Territory Covered (List states or provinces - whole or parts):

List all manufacturers you represent (Two REQUIRED for membership - this information is held strictly confidential):

1. Name:

Address:

Key Contact:

Phone:

2. Name:

Address:

Key Contact:

Phone:

3. Name:

Address:

Key Contact:

Phone:

Please enter any additional manufacturers here:

Do you as a representative own any interest in a company that manufactures products in the health care industry? Yes No
If yes, give the firm's name:
Do you as a representative own any part of a health care distributing company? Yes No
If yes, give the firm's name:

Please complete the following:

Do you have warehouse facilities available? Yes No
Do you invoice any lines? Yes No
If yes, list lines:

This information is for the directory - Our firm markets products to the following categories (check):

Acute Care/Hospital
      Anesthesia
      Bio Medical
      Capital Equipment
      Cath Lab/EP Lab
      Central SPD
      Dialysis
      ED
      G. I. LAB
      ICU
      Imaging
      Labor/Delivery/NICU
      Laboratory
      Oncology
      Operating Room
      PACU
      Pharmacy
      Physical Therapy/Rehab
      Respiratory
      Surgery Centers
      Wound Care
Primary Care/Physician
      Capital Equipment
      Chiropractic
      Disposables
Extended Care
      Capiral Equipment
      Nursing Homes
      Physical Therapy/Rehab
      Sub Acute Care
      VNA
      Wound Care
Home Healthcare
      Durable Med Equip
      Home IV Infusion
      Pharmacy
      Physical Therapy/Rehab
      Respiratory
Dental
Government
      DOD
      VA
Veterinary
OEM
Drug Wholesale
Imaging
Emergency (EMT)
Laboratory
Industrial Occupational Health
OTHER

CODE OF ETHICS

PREAMBLE
The economic well being of our nation is dependent on the effecient movement of goods and services from their producer to the ultimate consumer. The most efficient and cost effective way to accomplish this is through the use of manufacturer's representatives. The experienced professional representative knows his territory and the customers within it. He deals ethically and honorably with his principals and customers. He constantly enhances his knowledge of the product he represents and his ability to manage a successful business, and he strives to enhance the stature of his profession by raising the ability and standards of all its members.

The Health Industry Representative can have no greater guide than the Golden Rule enunciated two thousand years ago: "Whatsoever ye would that men should do to you, do ye even so to them."

The Health Industry Representative recognizes these precepts and pledges himself to observe both their essence and spirit in all of his activities and to conduct his business in accordance with the priciples set out in this HIRA Code of Ethics.

Article 1
The representative should conduct his firm in a well managed and fiscally stable manner. In so doing, he will faithfully perform both the letter and spirit of all of his agreements.

Article 2
The representative will conduct all of his business affairs honorably. He will deal truthfully with all he comes in contact with, avoid exaggeration, misrepresentation of concealment of pertinent facts and present the facts accurately in his representations and advertising.

Article 3
The representative will never degrade, malign or make false representations regarding a fellow representative or a manufacturer. He shall not volunteer opinions regarding a competitor. If his opinion is sought and if the representative deems it appropriate to respond, such opinion shall be rendered with strict professional integrity and courtesy.

Article 4
The representative will only agree to represent those lines which he can adequately, fully and fairly handle.

Article 5
For the betterment of his profession, the representative will willingly share the fruits of his knowledge and experience with other health care representatives and with others who can benefit from his knowledge.

Article 6
For the protection of all persons with whom he deals, the representative, to the greatest extent practicable, will see that his business and financial obligations and commitments are in writing. A copy of each written agreement will be given to every party to the agreement.

Article 7
A health care representative will keep himself informed on the products that he represents on all governmental laws and regulations pertaining to his business so that he can provide competent service to his customers and principals.

Have you read, and do you subscribe to, the Association's "Code of Ethics"? Yes No

SPONSOR: Please indicate if a HIRA member is sponsoring your application. Three (3) HIRA Member sponsors are required if the firm applying has been in operation less than one (1) year.

Name: Firm Name:

Name: Firm Name:

Name: Firm Name:

Representative Membership is $325.00 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