International Telecommunication Professionals Exchange


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	Platinum Sponsorship Registration

Please provide the following registration information:

Prefix
First Name
Last Name
Title
Organization
Address
City
State/Province
Zip/Postal Code
Country
Telephone
Fax
E-mail

Which of the following best describes
your company's primary operations?
(Please check only one)

Telephone Company
Supplier/Distributor
Installation/Service
Equipment Manufacturer
Consultant
Sales Agent (Region) r
Other

Please describe your company's product line or service:

Payment Method
Federal Tax I.D. #20-3930683

Amount Due: $10,000.00 (US Funds)
Check enclosed, payable to ITPX
MasterCard
Visa Card
American Express - Not Available

Card Number

Expiration Date

Cardholder Name (as it appears on your billing statement)

Address (as it appears on your billing statement)

City (as it appears on your billing statement)

State/Province (as it appears on your billing statement)

Zip/Postal Code (as it appears on your billing statement)
The International Telecommunication Professionals Exchange (ITPX) has permission to release my name and the above information (excluding payment information) to companies in the telecommunications field.