MiCTA Service Corporation
1500 W. High St.
Mt. Pleasant, MI 48858
Voice (989) 317-0334
Fax (989) 317-0335 

MSC Program Participation Form
 
Please complete the following information:
Organization Name:
Primary Contact:
Title:
Area(s) of Responsibility:
Telecommunications Budgets/Finance Video Network/Equipment
Computer Services/Info Tech Purchasing LAN/Data Network
Other
Address:
City, State and ZipCode:
Country:
Phone:
Fax:
E-mail:
Organization Internet URL:
Institutional Information
Please indicate the size of your organization:     
  FTE Employees (Full Time Equivalent)
Please identify your main line of business that most closely represents your organization
College & University K-12 Local Government
State Government Federal Government
Healthcare Library Religious, Charitable or Other
 
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Second Contact:
Title:
Area(s) of Responsibility:
Telecommunications Budgets/Finance Video Network/Equipment
Computer Services/Info Tech Purchasing LAN/Data Network
Other
Address:
City, State and ZipCode:
Country:
Phone:
Fax:
E-mail:
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Third Contact:
Title:
Area(s) of Responsibility:
Telecommunications Budgets/Finance Video Network/Equipment
Computer Services/Info Tech Purchasing LAN/Data Network
Other
Address:
City, State and ZipCode:
Country:
Phone:
Fax:
E-mail:
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Fourth Contact:
Title:
Area(s) of Responsibility:
Telecommunications Budgets/Finance Video Network/Equipment
Computer Services/Info Tech Purchasing LAN/Data Network
Other
Address:
City, State and ZipCode:
Country:
Phone:
Fax:
E-mail:
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Fifth Contact:
Title:
Area(s) of Responsibility:
Telecommunications Budgets/Finance Video Network/Equipment
Computer Services/Info Tech Purchasing LAN/Data Network
Other
Address:
City, State and ZipCode:
Country:
Phone:
Fax:
E-mail:
Please identify any additional personnel responsible for the following areas if not identified above.
A.  Telecommunications
B.  Budget/Finance
C.  Video Network/Equipment
D.  Computer Services/Info Tech
E.  Purchasing
F. LAN/Data Network
Survey Information
What is your primary reason(s) for participating in MSC programs?
How did you hear about MSC?
Your Participation Number will be emailed to you.

MiCTA Service Corporation
1500 W. High St.
Mt. Pleasant, MI 48858
Attn: Clancy DeLong

Voice (989) 317-0334
Fax (989) 317-0335