Associate Member Application Form - WTA Advocates for Rural Broadband

Company Information:

2023 WTA Associate Membership Dues are $900 (January 1-December 31, 2023). Dues are NOT prorated.
Please complete the application and return with payment to WTA Advocates for Rural Broadband.
Please make sure all information is accurate and up-to-date, and attach any additional information if necessary.

Company Name *

Acronym (if applicable)

Headquarter's *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Website *

Social Media

Description of Services *

Primary Contact

Name *

First

Last

Title

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Secondary Contact

Name

First

Last

Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Membership Fee

Payment method *

Invoice - $ 900.00
Credit card - $ 930.00

Note: The membership fee is $900.00 (with a $30.00 processing fee when paying by credit card).

Credit Card *

Card

Name on Card

Questions?

Contact Kelly Worthington by phone at 406-443-6477 or email kelly@w-t-a.org for help.

Company Information:

Primary Contact

Secondary Contact

Membership Fee

Questions?

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