Independent Representative Information Request

If you would like more information on becoming an Independent Representative please take a moment to complete the following questions. Information submitted will be used by Timberpeg^® only, it will not be given to anyone else. Someone will contact you shortly upon completion. Items marked with an asterisk are required fields.

Contact Information

First Name: *

Last Name: *

Street Address: *

Street Address 2:

City: *

State: *

Zip: *

Country: *

Phone Number: *

When is the best time to call you?:

Company name:

If you currently operate as or own a company please tell us the legal name. I.E. "Smith Construction LLC".

Email Address:

Company website:

Please contact me via:

Email

Phone

How did you hear about us?

Magazine Ad (Choose from the list):

Independent Representative Info

If other, please describe:

In what geographic area(s) would you like to be an Independent Representative?:

Please describe any related experience you have which you feel would make you a good Independent Representative:

How did you become interested in Timberpeg®?: