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Micta Service Corporation
1500 W. High St.
Mt. Pleasant, MI  48858  
Voice (888) 870-8677
Fax (989) 772-3239  
membership@mictaservice.com

Micta Service Corporation Member Application 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:
Check here if you would like to be added to the MiCTA/ATAlliance ListServ
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 Government/Public Sector
Healthcare Library Other
 
Click here if you have no more contacts, or continue scrolling to add more.
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:
Check here if you would like to be added to the MiCTA ListServ
Click here if you have no more contacts, or continue scrolling to add more.
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:
Check here if you would like to be added to the MiCTA ListServ
Click here if you have no more contacts, or continue scrolling to add more.
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:
Check here if you would like to be added to the MiCTA ListServ
Click here if you have no more contacts, or continue scrolling to add more.
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:
Check here if you would like to be added to the MiCTA ListServ
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 joining MiCTA?
How did you hear about MiCTA?
Are you a current member of or represented by any of the following organizations?
ACUTA MHEC
NEBHE SREB WICHE

Fax:(989)772-3239
Phone: (888)870-8677
E-Mail: membership@mictaservice.com

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

 
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