Friends of MPIBA Membership - Mountains and Plains Independent Booksellers Association

Friend of MPIBA Enrollment Form, Fiscal Year 2021-22

This form is for authors, libraries, and other individuals or organizations looking to support MPIBA. All other prospective industry members (i.e. publishers, commission sales reps) should use the Industry Member form.

Organization Information

Organization Name

Select Your Membership Category*

Other - Please Specify*

Your Name*

First Last

Email*

Phone*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Who else from your company should be included on our contact list?

Name	Job Title	Email Address

Payment

Optional Donation to Support our Bookseller Grant Programs

Donations support MPIBA's various bookstore grant programs, including travel, professional development, and store improvement grants.

Total

$0.00

Coupon

Credit Card

Card Details

Cardholder Name