VTIA AFFILIATE MEMBERSHIP APPLICATION FORM

Please complete and return this form. Dues for affiliate membership is $350 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.

Please list us in the VTIA directory as being in the business of (limit six words):

Current Virginia telecommunications company customers: