IPC and WHMA Membership Application

Member Company Information
Company Name:*
 
Company Name Variations:*

(List all company, parent company or division names used in the last five years. Please include any merger or acquisition name changes so we can update our records)
 
Primary Membership Location
Street Address:*
 
City:*
 
State/Province:*
 
Country/Region:*
 
Postal Code:*
 
Company  Website:*
 
Number of Employees Corporate-wide:*
 
Global Revenue:* $

Please include total revenue for your parent company in US Dollars
IMPORTANT: Enter only whole numbers in this field; no decimal places and no commas.
 
Is the above location the corporate headquarters?*
Primary Membership Contact
First Name:*
 
Last Name:*
 
Title:*
 
Phone:*
   
E-Mail:*

Billing Contact - (the key contact for invoices and statements)
 
First Name *
 
Last Name *
    
Title:*
 
Phone *
   
E-mail *
Government Relations Contact
 
First Name
Last Name
Title:
Phone
E-mail
Training Contact - (the key contact for training of staff)
First Name
Last Name
  
Title:
Phone
E-mail
To best serve your specific needs, please indicate the most appropriate member category(s) for your company.
Primary Company Category *
(choose one)











 
Secondary Company Categories
(select all that apply)
 








 

Industries you serve
(select all that apply)
 










 
 
   
Membership Selection
NEW! Receive 50% off your first year for first time members! Past membership will be verified upon receipt of your application.
Has your company been an IPC Member in the past?*
Select Membership Type*
(View Membership Options)

Select Membership Duration*

 

Amount Due: $ 0.00

(View Membership Dues Table)

Method of Payment
Make check payable to IPC and mail to the lock box address below:
  IPC
3491 Eagle Way
Chicago, IL 60678-1349
 
Include your company name and reference IPC MEMBERSHIP
  Wire Transfer Instructions
ACH:
071000013
IPC Account Number:
18231861
Domestic Wire Transfers
Wire Routing Number/ABA: 021000021
Bank Name: JP Morgan Chase Bank, N.A.
City, State: New York, New York
Account Number: 18231861
Title of Account Number: IPC
International Wire Transfers
Wire Routing Number/ABA: 021000021
SWIFT CODE: CHASUS33
Bank Name: JP Morgan Chase, N.A.
City State: New York, New York
Account Number: 18231861
Title of Account Number : IPC
 
 Please check here if you require an official invoice from IPC.
Form Submitted By
Please enter your contact information below. Email confirmation of this application will be sent to the email address below.
First Name *  
Last Name *     
Phone *  
E-mail *