Register as a Vendor

iMedia, Inc. is excited to represent your products and services!

Generally if your company has products for us to sell your company will drop ship under iMedia's associate's company name and logo.

We will supply you with "White Box" shipping labels and packing lists.

We will explore the best way for us to transmit orders to your ordering system.

Salutation:

-none- Mr. Ms. Mrs. Dr. Prof.

First Name: *

Last Name: *

Company Name:

Department:

Email Address: *

Other Email:

Title:

Mobile:

Office Phone:

Home Phone:

Other Phone:

Fax:

Website:

Primary Address Street:

Primary Address City:

Primary Address State:

Primary Address Postalcode:

Primary Address Country:

Alt Address Street:

Alt Address City:

Alt Address State:

Alt Address Postalcode:

Alt Address Country:

Assistant:

Assistant Phone:

Referred By: