Tech Support Request Form

MEMBERSHIP APPLICATION

See Dues for a full explanation of membership dues.

Fill out all * required information and click "Submit" below.

TYPE OF MEMBERSHIP (Please check any that apply)

WSTA Active Member Telephone Company
WSTA Active Member Internet Service Provider
WSTA Active Member Wireless Service Provider
WSTA Associate Member (Supplier or Service Organization)

COMPANY INFORMATION

	Name of Company:
	Address:
	City:
	State:
	Zip Code:
	Telephone Number:
	Fax Number:
	E-mail Address:
	Website URL:

FOR ACTIVE TELEPHONE COMPANY MEMBERSHIP APPLICANTS

Number of access lines served
as of December 31, 2001

FOR ACTIVE INTERNET SERVICE PROVIDER MEMBERSHIP APPLICANTS
Size of Company?

Under
$500K

$500K
to $1M

$3M
to $5M

$5M
to $10M

over
$10M

What is your company's product or services?
Nature of Business: (Manufacturer, Wholesale, Retail, Service, Other)
Sales Territory:
Total Number of Employees:
Total Number of distributors/dealers/agents:

FOR ACTIVE WIRELESS SERVICE PROVIDER MEMBERSHIP APPLICANTS

Serving Territory:
Number of Customers as of 12/31/01:
Number of Employees:

FOR ASSOCIATE MEMBERSHIP APPLICANTS
Briefly describe the product you sell or services you render:

What does your company have in common with telephone companies and cooperatives and/or Internet Service Providers?

FOR ALL MEMBERSHIP APPLICANTS
Please list your organization's officers:

	President:
	Secretary:
	Vice President:
	General Manager:

To whom shall invoices for membership dues be directed:

	Name:
	Address:

To whom shall Association Bulletin and correspondence be directed:

	Name:
	Address:

Send a copy to myself




Please type in the security code you see above.

Security Code:

Fill out all required information and click "Submit"

(

indicates a required field)