Publishing Company Name *
Street Address *
City *
State/Province *
ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIowaIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNewfoundlandNew BrunswickNorthwest TerritoriesNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanYukonU.S. Territories:GuamVirgin IslandsPuerto RicoOther
Zip/Postal Code *
PO Box
ZIP/Postal Code
Phone *
(just numbers. No hyphens or spaces)
Fax
E-mail *
Website Address
Name of Key Contact *
Has the company previously been assigned BIPAD number(s)?
YesNo
If Yes, the number(s) is (are)
Does the company have a "GSI" or "Uniform Code Council" (UCC) Company Prefix number?
Number of titles for which BIPAD numbers are to be allotted
(A different BIPAD number must be used with each title publication for which separate
distribution records are to be maintained by wholesalers. It is not necessary to obtain a different BIPAD number for each issue)
FEE SCHEDULE *
BIPAD Numbers
Fee
1
$375
3
$750
5
$100
11-15
$2625
2
$550
4
$900
6-10
$1750
16-20
$3500
*Multiple number fee rates are not retroactive and are available only at time of original application.
NAME OF TITLES
(A different BIPAD number is required for each title, but not for each issue)
ISSUE FREQUENCY
NAME OF MAGAZINE WHOLESALER/DISTRIBUTORS
LOCATION CITY
STATE
Clear Form
