2025 Individual Membership Form

Individual Membership Form

Publisher / Sales Rep / Author / Distributor / Sideline / Friend to PNW Booksellers
Member Name*

First NameLast Name
Organization Name*
For Authors, this may be your Name again.
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Member Phone:*

Area CodePhone Number
Member E-mail:*
Organization Web Site:
Member Category*

PublisherSales RepAuthorPublicistSidelinesOtherDistributor
Publishers, Publicists, Reps, Distributors, & Sidelines, if you would like to upload a Company Logo, please submit your information here.

You may upload one 10 MB photo.
Organization Logo:

Browse Files
JPG or PNG Cancelof
Reps, if you would like to submit a Rep photo and territories that you cover for the Member page on our website, please submit your information here.

You may upload one 10 MB photo.
Rep Photo

Browse Files
JPG or PNG Cancelof
Rep Territory
Additional Comments
Payment
Individual Membership
Total
Total Payment

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Individual Membership Form