RCA Affiliate Member Application « Rural Cellular Association

RCA Affiliate Member Application

Alternatively you can download a copy of this form here and mail us a check.

Company Name (required)

Contact Person (required)

Contact Title (required)

Website Address (required)

Company Address (required)

Company City (required)

Company State (required)

Company Zipcode (required)

Company Phone (required)

Company Fax (required)

Please provide a brief description of your company’s products and/or services:

Contact E-Mail (required)

Billing Contact (required)

Billing Title (required)

Billing Phone (required)

Billing Fax (required)

RCA requires new applicants to have an existing RCA Member sponsor and a letter of reference from that member.

Name of Sponsoring Company(required)

Name of Sponsoring Individual (required)

Annual Membership Dues: $1500

Billing Address (required)

Billing City (required)

Billing State (required)

Billing Zipcode (required)

Credit Card Type

Name on Credit Card (required)

Card Number(required)

Expiration Date MM/YY format(required)

Acceptance (Signature Required)