Online Application Form

Please Complete All the Following Information

Company Information

How many stores do you own?

Company Name:

Address:

City:  State:  Please select one ... ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip:

Telephone:  Fax:

Email:  WebSite:

Office Location If different from above

Address:

City: State: Please select one ... ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip:

Telephone: Fax:

Email: WebSite:

Branch Location

Address:

City: State: Please select one ... ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip:

Telephone: Fax:

Email: WebSite:

Owner Information:

Owner's Name: Owner's Title:

If owner would like to designate an employee to actively participate as the IPI member on his/her behalf, please fill in the following information:

Employee's Name: Email Address:

Type Of Ownership

Sole Proprietor Partnership Corporation Limited Liability Company

Does owner owns more than 50% of each lab location?   Yes No .... Indicate if owner is a member of   PRO T&C .... $2000 initiation for new member will be deferred and collection amortized via member’s annual patronage distribution. $500 transfer fee will be due and payable if membership is transferred (purchased IPI member business). Membership dues are $100/month and are automatically withdrawn from member’s checking account. Approximately one to two days after receiving your application, Brenda DiVincenzo, Director of Operations & Membership for IPI will set you up as a new member. Your IPI member lab number and your user name and password for www.ipiphoto.com will be sent to you via email. Please submit any questions to Brenda at brenda@ipiphoto.com or (702) 617-1141 ext 205# or (702) 524-1415.