Company Info

Company Name (required)

Contact Name (required)

Mailing Address (required)

City (required)

State (required)
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Zipcode (required)

Contact E-Mail (required)

Company Phone (required)

Sponsorship Details

Topic Title (required)

Topic Description (required)

 I am/my company is interested in serving on a webinar panel

 My company would like to sponsor a webinar ($2,000 per webinar)

Payment Info

Method of Payment
Select Payment TypeCheckMaster CardVisaAmerican ExpressDiscover

Name on Credit Card (required)

Card Number(required)

Expiration Date MM/YY format(required)

Billing Contact (required)

Billing Title (required)

Billing Phone (required)

Billing Address (required)

Please make checks out to Rural Cellular Association and send to:
805 15th St.
Suite 401
Washington, DC 20005

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