Print This Page, Fill-In the Information and Mail with Your Check for $30.00USD
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	Listing Form for 2009-2010 North America's Premier Manufacturers Representative Listing Service
To be listed on Repfind.Com complete this form and return it with your $30.00USD listing fee payable to Albert L. Hass, 713 Blvd Street, Fremont, NE 68025. Other contact information below. Please Type or Print Clearly
Agency Name:
Mailing Address:
City, State/Prov, Zip/Postal Code:
Shipping Address:
City, State/Prov, Zip/Postal Code:
Contact:                                                               E-mail:
Web Site:
Territory Covered:
Warehouse:         No           Yes, How many:
Telephone:                                                        Add'l Telephone:
Fax:                                                                   Add'l Fax:
Lines: (Please list alphabetically)
Additional Information: (branch offices, warehouses, etc.)
By signing below you agree to be bound by the terms and conditions contained in the "Listing Agreement" found on Repfind.Com. Listing Fee is $30.00USD for twelve months. Listing period is October 1st through September 30th. There is no price reduction for a period of less than twelve months.
Your Name:                                                                  Title:
Signature:
Please Note: Make your check payable & mail to: Albert L. Hass 713 Blvd Street Fremont, NE 68025 Contact Info: Tel: 402-320-9387, E-mail: alhass@repfind.com