ICCBBA - APPLICATION FOR VENDOR REGISTRATION-FINAL

ICCBBA - APPLICATION FOR VENDOR REGISTRATION
- Registration processing will take approximately 2-4 weeks.
- If you are unable to submit te completed form online, please submit completed form to ICCBBA, P.O. Box 11309, San Bernardino, CA 92423-1309 USA
If you need assistance with completing this form, please contact our staff by emailing registration@iccbba.org or call +1 909 793 6516.
1. Full, legal name of company registering:*
2. Contact person (business) to whom business mailings (e.g., invoices) should be sent:*

Job TitleFirst NameSurname
E-mail (Business)*
example@example.com
3. Contact person (technical) if different from the above contact. This would be the person who needs technical updates (e.g., ISBT 128 specification and database information:*

Job TitleFirst NameSurname
E-mail (Technical)*
example@example.com
4. Contact person (marketing) if different from the above contacts. This would be the person from your company who would provide ICCBBA with your company information for posting on the ICCBBA website.:*

Job TitleFirst NameSurname
E-mail (Marketing)*
example@example.com
5. Legal business address of firm:
Country*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. Telephone and fax number:
Country Code*
Tel*
Fax
7. Corporate website address (URL of the vendor name on the ICCBBA site should link to):
8. Billing Address:
Department*
Country*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PART C:
1. Signature of authorized person: I request registration of the above-named company by ICCBBA. I agree to the terms and conditions of the License Agreement and understand that an annual license fee (payable when invoiced) will be required to maintain this registration. I represent and warrant that I have full authority to bind my organization to the terms and conditions of the License Agreement.
Signature* Date*
Printed Name*
Position*
World Bank Classification
- If your company is in a country classified as Upper-Middle Gross National Income per capita,your license fee will be reduced by 10%.
- If your company is in a country classified as Lower-Middle Gross National Income per capita, your license fee will be reduced by 33% and the registration fee will be waived.
- If your company is in a country classified as Low Gross National Income per capita, your license fee will be reduced by 66% and the registration fee will be waived.
Information on country classification is available from the World Bank at: https://data.worldbank.org/
Payment Options: We accept credit cards (Visa and Mastercard only), wire transfers, and ACH payments. Please submit your completed registration form to us for review and we will reach out to you with an invoice with the appropriate amount due at the time of registration. Please do not send any payments before your registration form is submitted.
NO PURCHASE ORDERS
Credit Card (VISA or MasterCard only)

For credit card payments, we will email you your invoice. Once you receive the invoice, pleasevisit our online payment portal at: https://iccbba.org/payment-portal/ No telephone orders accepted.

Bank Draft/Wire

Transfer appropriate amount to: Bank of America, NA222 Broadway, New York, New York, 10038Bank Number 053000196 BIC/SWIFT: BOFAUS3NPayable to: ICCBBA, Account Number 000683127591