IPI U.S. Membership Application

IPI U.S. Membership Application
Company Information

Please provide all of the following information completely and accurately. All fields marked with an "*" are required.
Company*
Include dba if applicable
How many total physical locations do you have?*
Primary Location Physical Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Is this your preferred mailing address?*

YesNo
Is this your preferred billing address?*

YesNo
Primary Location Phone Number*
Please enter a valid phone number.

Owner Information
Name*

First NameLast Name
Email*
*Please verify your email address before proceeding to the next field.
Best Contact Number*
Please enter a valid phone number.
Type of Ownership*
Select One
Does the owner applying own more than 50% of the business? *
You may designate an employee to act as the main contact to IPI on behalf of the owner. While the owner still needs to be the point of contact for elections and patronage distributions, an owner that is not directly involved in the aspects of their business that would be affected by IPI benefits, is encouraged to designate an employee to participate on his/her behalf.
As the owner, are you also the main IPI contact for the company?*

YesNo
As the owner, are you also the accounts payable contact for the company?*

YesNo
Are you a member of any of these groups?

PRO MemberPRO AffiliateIndependent Photographic Supplies (IPS) - AustraliaCamera House (Australia)Foto Source Member (Canada)
What goal(s) do you wish to achieve by becoming an IPI member?

Company Online Presence Information

List all that apply
Website *
Facebook Page
Company LinkedIn Profile
YouTube Channel
Instagram Page
Pinterest Account

Additional Location Information

If you have more than one physical location, please provide the following information for your other locations. Each physical location will be assigned a separate IPI number at no additional charge. If you have more than three physical locations, please email a full list of your locations to brenda@ipiphoto.com.
Additional Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Additional Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Main Contact Information

You may designate an employee to act as the main contact to IPI on behalf of the owner. While the owner still needs to be the point of contact for elections and patronage distributions, an owner that is not directly involved in the aspects of their business that would be affected by IPI benefits, is encouraged to designate an employee to participate on his/her behalf.
Main Contact Name

First NameLast Name
Main Contact Email
example@example.com
Main Contact Best Number
Please enter a valid phone number.
Main Contact Role

Co-ownerManagerEmployee

Accounts Payable Contact Information
Accounts Payable Name

First NameLast Name
Accounts Payable Email
example@example.com
Accounts Payable Best Number
Please enter a valid phone number.

Additional Employees

Please list any additional employees you would like to have access to our website and be placed on various email distribution lists for information on vendors, marketing, networking, education and events.
Employee 1

First NameLast Name
Email
Employee 2

First NameLast Name
Email
Employee 3

First NameLast Name
Email

Application Agreement

Signature Required for Application to be Considered
Applicant represents and warrants that neither applicant nor any of his/her/its officers, directors and employees, if any (collectively “Applicant”), are restricted or prohibited, contractually or otherwise, from applying for or, if accepted, becoming a member of the Independent Photo Imagers, a Delaware Corporation (“IPI”) and that Applicant’s completion of this Application, and if accepted by IPI, becoming an IPI member, will not violate any rules or law or breach any agreement between Applicant and any third person or entity. In the event of a breach of Applicant’s representations and warranties set forth in this paragraph, Applicant shall indemnify, defend and hold IPI and its officers, directors, shareholders, agents and members (the “IPI” Parties) harmless from and against any and all loss, liability, claims, causes of action, demands, costs and expenses, including attorney’s fees, arising out of or related in any way to Applicant’s breach thereof. In the event the IPI Parties are ever made a party to any action or proceeding by reason of any manner for which Applicant has hereby agreed to indemnify the IPI Parties, then Applicant, upon notice from the IPI Parties, shall defend such action or proceeding on behalf of the IPI Parties at Applicant’s expense by counsel chosen by the IPI Parties. If accepted as a member, applicant specifically agrees to abide by the terms and provisions of the bylaws of IPI, as amended. Upon written request, a complete copy of said bylaws will be provided to applicant. Applicant hereby specifically agrees to provide any additional information necessary to process this application directly to IPI’s home office in Henderson, NV.
Consent

By providing your signature, you are consenting to employees of your business receiving electronic messages from IPI - Member Network, including, but not limited to, email, social media and text.
Signature*

Clear
Full Legal Name of Signatory *

First NameMiddle NameLast Name
Title of Signatory*
Today's Date*

MonthDayYear
Date
In order for this application to be processed, two additional forms must be submitted:
1. Complete, signed W-9 Form. The information provided will be verified with the IRS. Click here to complete: https://form.jotform.com/213345727286158.
2. Complete, signed Electronic Payment Authorization Form. Click here to complete: https://form.jotform.com/90435257822155. This form includes payment arrangement for the following:
  1. Membership dues
  2. Optional services
  3. Any up-front fees:
    
    Initiation Fee - Full deferment to annual patronage distribution is currently available. $0 DOWN!
    
    Ownership Transfer Fee, if applicable - Did you purchase a business from an IPI member?
    
    Reinstatement Opportunity Fee, if applicable - Were you previously an IPI member?
All applications are subject to approval by the IPI Board of Directors within 12 months of receipt. Approval is at the sole discretion of the Board, upon the advice of the Vice President of Member Success and Executive Director and based upon the information collected throughout the application process.

If approved, you will be set up as a member and you will receive an email containing all important details, including your IPI membership number and your username and password for https://www.ipiphoto.com/. Please submit questions about IPI membership to Brenda DiVincenzo, Vice President of Member Success, at brenda@ipiphoto.com or (702) 524-1415.
Hidden Text Field - Main Contact Email
Hidden Text Field - AP Email
Hidden Text Field - Employee 1 Email
Hidden Text Field - Employee 2 Email
Hidden Text Field - Employee 3 Email
Should be Empty:

IPI U.S. Membership Application

Company Information

Owner Information

Company Online Presence Information

Additional Location Information

Main Contact Information

Accounts Payable Contact Information

Additional Employees

Application Agreement

Consent