Kentucky Telephone Association

Membership Application Form

My company submits this application to join the Kentucky Telephone Association and agrees to support and adhere to its rules and policies. A check for the annual dues will be mailed. We seek to join KTA under the following membership classification (please check one).

    Regular Member - We are a state regulated local exchange company operating within the Commonwealth and provide "wireline" telecommunication services to the public.

    Affiliate Member - We are a toll, cellular or other communications company and provide telecommunications services within the Commonwealth.

    Associate Member - We are a company providing direct services to the telecommunications industry, such as manufacturing and supply of goods and equipment, contracting and other professional services. The 2007 associate member dues are $250 for basic or $1,000 for premium level membership. Associate
member benefits are set out below.

Company Name   

Street Address         

Mail Address              

City ST Zip            Web Site

Type of Business

Executive Contact:

Name                 Title:

Street Address   

Mailing Address 

City                              ST    Zip 

Phone      Fax    

Email   

Local Contact:

Name                 Title:

Street Address   

Mailing Address 

City   ST    Zip 

Phone     Fax  

Email   

NOTE:  The local contact will be the primary contact for KTA correspondence, meeting announcements, invoices and general information.  Contact the office if other arrangements or contact persons are desired.

Additional Comments: