Associate Member Application - Pennsylvania Telephone Association

To the Board of Directors:

After due consideration of the benefits to be derived through membership in the PENNSYLVANIA TELEPHONE ASSOCIATION, the undersigned hereby makes application for ASSOCIATE Membership, subject to the approval of this application by the Board of Directors of the Association.

Annual Dues: $375.00

State here what you manufacture, sell, or services performed for telephone companies:*

(this information is listed in our membership directory and on our website)

Company*

Address*

City, State, Zip*

Representatives

How many representatives would you like to register?

You may name up to three (3) representatives.

Representative Name*

Title*

Work Phone*

Fax

Cell

Email*

Website*

Contact Options*

Directory Contact
Meeting Information
Friday Report
Billing/Invoices

Please select the appropriate categories.

Representative #2

Representative #2 Name

Title

Work Phone

Fax

Cell

Email

Website

Contact Options

Directory Contact
Meeting Information
Friday Report
Billing/Invoices

Please select the appropriate categories.

Representative #3

Representative #3 Name

Title

Work Phone

Fax

Cell

Email

Website

Contact Options

Directory Contact
Meeting Information
Friday Report
Billing/Invoices

Please select the appropriate categories.

Payment*

I will mail a check made payable to Pennsylvania Telephone Association and mail to 30 North Third Street, Suite 780, Harrisburg, PA 17101
I will pay by credit card: Please call PTA at 717-238-8311

Please note that Payment cannot be made online.

Name

This field is for validation purposes and should be left unchanged.