VTIA COMPANY MEMBERSHIP APPLICATION FORM

(Please complete and return this form. Your dues will be assessed based on your operating income and you will be billed accordingly. If you have questions, contact VTIA.)

Corporate Name
Mailing Address
City/State/Zip
Telephone	Fax
E-Mail

Please list the company contacts and their responsibilities:

Name	Responsibility	Phone/Fax/E-mail

Please include additional names if appropriate.

Describe the telecommunications service(s) you provide to end users in Virginia:

Please indicate the committees your primary representative or another executive would like to join:

Committee	Name of Participant
Customer Service
E-911
Finance & Accounting
Human Resources/Training & Safety
Inter-Company Compensation
Interexchange Carriers
Internet Service Providers
Legislative
Membership
Network Facilities
Public Relations
Small Company
Wireless

(All appointments to committees are made by the president and confirmed by the board of directors.)