The Association for
Hose and Accessories Distribution
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HSI Advisory Council Application
Qualified Individuals are invited to apply to serve as a member of the Advisory Council by completing this application form.
Name:
Title:
Company Name:
Email Address:
Work Phone:
Cell Phone:
Address:
City:
State/Province:
Zip/Postal Code:
Describe Current Position and Responsibilities:
Please describe your work or experience with hose assemblies or hose applications:
With which industries and products do you work most frequently?
What would you hope to accomplish as a Hose Safety Institute Council Member?
choose one
Yes
Do you have the authority to commit the time required for this role?
Supervisors Name:
Supervisors Title:
Supervisors Email:
Referred By:
choose one
Yes
I have read and understand the requirements for, and responsibilities of, membership on the Hose Safety Institute Advisory Council and agree to comply with them if selected to serve.
- denotes required fields
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