Independent Publishers Bookstore (IPB)
Internet Services Order Form

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Any Information You
Provide Is Encrypted
For Your Security

Use the secure electronic form below to:
   * Register for Reader-to-Publisher Direct Online Bookstore
   * Order the Secure Order System
   * Link IPB to your Existing Website
   * Open a new Website (with link) on IPB

If you are signing up for Reader-to-Publisher Direct, be sure you have read the Terms & Conditions page.

For fastest service, submit the completed form ONLINE via our SECURE SERVER. Any information you provide will be kept strictly confidential. If you prefer, you may place your order via phone, fax or mail. Call us Toll Free at 1-800-644-6901 (orders only), locally at 719-395-5700. Or you may complete and print the form below and send it by fax or mail. Fax: 719-395-5795, Mail: VistaWorks, P.O. Box 4629, Buena Vista, Colorado 81211.

Please provide the following contact information so we may complete your order:
(Fields marked with * are required.)

Contact Information
* Name:
* Company:
* Address:
* City:
* State / Province: * Zip / Postal Code:
* Day Phone:
* Email:

Check the box next to the service you want to order and provide any additional info requested.

IPB Service
Total Price
Reader-to-Publisher Direct Online Bookstore Registration Fee: $35.00
Value added option
(with Online Bookstore Registration ONLY)

Secure Order System
Requires credit card merchant account
Setup: $40.00
Value added option
(with Online Bookstore Registration OR Standalone)

Offsite Link to my existing Website
Existing Site URL:
Setup: $15.00
3-month link fee: $29.85
Value added option
(with Online Bookstore Registration OR Standalone)

Design & Host New Website
Setup: $35.00
3-month hosting fee: $74.85
Site Design @ $65/hr. not included

So we can complete your order, please provide your payment information below (we accept Visa and Mastercard):
(Note: All entries must be completed.)

Payment Information
Card Type:
Card Holder's Name:
Card Number:
Expiration Month: Expiration Year:
Card Billing Address:
Card Billing Zip:

Have questions, comments, specials instructions? If so, use the following Comments / Additional Info box:

Comments / Additional Info

If you have completed filling in the info above, please press the following button to calculate and review your form:

Calculate & Review Form
Press This Button

Then Wait For Review Page To Display


Independent Publishers
VistaWorks; PO Box 4629; Buena Vista, CO; 81211
Toll Free: 1-800-644-6901; Local: 719-395-5700

Site Design & Hosting by VistaWorks
Copyright © 1999 Vision Technologies, Inc.
Rev. 10/3/00 jmb