Membership Registration

Please check the appropriate category of membership

Telecommunications Provider (Annual dues based on company size)

Associate Member (Annual dues = $375)

Premier Associate Member (Annual Dues = $1000)

Company Name *

Date Formed *

Principal Name *

Principal Title *

Street and Mailing Address *

P.O. Box (optional)

City *

State/Province * Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming US Military America US Military Europe US Military Pacific Outside US and Canada Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia

Zip *

Country

Phone *

Fax

Toll Free

Website Address

Name, Title, & Email of person to receieve OTA correspondence, event mailings, & newsletter *

Name, Title, & Email of person to receieve dues, invoices, and direcory update requests *

Name and Title of Northwest Representative

Title *

First Name *

Last Name *

Address (if different from above)

City

State/Province Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming US Military America US Military Europe US Military Pacific Outside US and Canada Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia

Zip

Country

Email Address

Description of Telecommunications Products and Services Offered

Geographic Area Served