Industry Membership Form - Mountains and Plains Independent Booksellers Association

Industry Membership Enrollment Form

This form is for publishers, wholesalers/distributors, commission sales groups, non-book vendors, book publicity companies (agents, media, publicists, book reviewers, bloggers, etc.), and book industry service providers. All other prospective industry members (i.e. authors, librarians) should use the Friends of MPIBA membership form.
Organization Information
Organization Name*
Company Type*
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
Select Your Membership Category*
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
Hidden
Number
Credit Card
Card Details
Cardholder Name

Name	Job Title	Email Address

Organization Information

Designated Voting Member

Contact for Bookseller Members

Payment