Industry Membership Form - Mountains and Plains Independent Booksellers Association

Industry Membership Enrollment Form, Fiscal Year 2021-22

This form is for publishers, wholesalers, distributors, commission sales groups, and non-book vendors. All other prospective industry members (i.e. authors, librarians) should use the Friends of MPIBA membership 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

Designated Voting Member

One representative from each Active Industry Member organization is allowed to vote on association business. If your organization would like to participate in votes, please indicate your voting member below.

I am the voting member

I am my company's voting member

Voter's Name

First Last

Voter's Email

Contact for Bookseller Members

One benefit of your membership is being listed on our website in the Vendor Database. Below you may provide the information you would like us to share with our booksellers. If there is any information you would not like listed, simply leave the field blank.

Company Website*

Name of Primary Contact for Booksellers

Phone

Email

Brief Description of Company

Optional Additional Information

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.

Coupon Code

Total

$0.00

Credit Card

Card Details

Cardholder Name