Wufoo

2008 Membership Application

Please visit Membership Types to view the different membership categories. Please select the category you believe is applicable. NATOA will determine whether the category is in compliance with the Bylaws, and will notify you of any change.
Please note that all memberships are on a calendar year basis; January 1 through December 31. Membership fees for new members joining after June 30 are prorated based on a half year schedule.

Name * Title First Last Suffix
Title *
Government Agency or Company *
Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Business Phone * - (###) - ### ####
Fax Number - (###) - ### ####
Email *
Web Site URL
If you are a Government representative, please provide the following information for your community/jurisdiction.
Population
Video Subscriber Base
Video/Cable Operator(s): All serving your Community
Video Franchise Expiration Date(s)
Telecommunications Provider(s) Serving your Community:
Government Members - Are you involved in: (please check all that apply) Accountant Attorney Cable/Video Franchise Enforcement Cable Rate Regulation Computer Systems Emergency Communications Engineer Government Access Channel I-NET Planning/Management Public/Educational Access Channel Telecom Planning Telecom/Telephone System Management Other
Please be sure to include those areas in which you have expertise or work on a regular basis.
Individual, Associate and Student Members (please check the most appropriate classification for your job). Access/Media Center Access/Media Center Supplier Accountant Attorney for Government Attorney for Industry Cable Industry Consultant for Government Only Consultant for Industry Engineer for Government Engineer for Industry Miscellaneous Student Telecom Industry
Public Educational Government Access

Please list the number of PEG Channels your community has:
No. of Public Access Channels:
No. of Educational Access Channels
No. of Government Access Channels:
Institutional Networks
Does your community have an I-NET? Yes No Under Construction
Government Agency Members

The Membership Fee for an Agency membership allows for one primary (voting) and two additional (non-voting) members to receive membership benefits. Please list up to two additional members with their complete contact information. (Name, Title, Address, Phone, Fax and Email).
First Additional Member Information
Second Additional Member Information
** An Agency Member may also add more than two additional members for the receipt of benefits, at the cost of $100 per individual. Please list those individuals to be added to the membership below, with their complete contact information. (Name, Title, Address, Phone, Fax and Email).
Name(s) and Contact for Additional Members at $100
Students - Please indicate school.
Payment Information:

Payment is based upon the appropriate membership category.
Membership Type - Dues Individual - $395 Agency - Population 0 - 25,000 - $420 Agency - Population 25,001-50,000 - $525 Agency - Population 50,001-250,000 - $790 Agency - Population 250,001-1,000,000 - $895 Agency - Population 1,000,000+ - $1,000 Associate - Non Profit - $370 Associate - Profit - $925 Student - $30
All Memberships Expire December 31 of each year.
Membership Type - Legal and Legislative Action Fund Assessment Individual - $125 Agency - Population 0 - 25,000 - $250 Agency - Population 25,001-50,000 - $375 Agency - Population 50,001-250,000 - $625 Agency - Population 250,001-1,000,000 - $950 Agency - Population 1,000,000+ - $1,250 Associate - Non Profit - $125 Associate - Profit - $375 Student - $0
Legal and Legislative Action Fund Assessment: The NATOA Bylaws establish an Annual Assessment for the purpose of the Legal and Legislative Action Fund, in addition to the annual membership dues. The recommended amount of contribution is based on the type of membership.
Additional Agency Member Fee:

If adding additional members over the two allowed in an Agency Membership, add $100 per individual added.
Total Dues, Assessment and Additional Agency Member Fees:

Be sure to sum the appropriate dues category, assessment and additional member fees for your total.
Enter Fee Here: $ .Dollars Cents
Government Purchase Order No:
Credit Card Processing is Temporarily Disabled.

We are in the process of upgrading our E-commerce tool to ensure the security of your credit card information. Please bear with us during this upgrade. You may still submit your application. If you want to use a credit card, first submit your application and then email NATOA at info@natoa.org for information on how to make a credit card payment. Thank you for your patience and your participation!
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Wufoo

2008 Membership Application

Public Educational Government Access

Institutional Networks

Government Agency Members

Payment Information:

Total Dues, Assessment and Additional Agency Member Fees:

Credit Card Processing is Temporarily Disabled.