Applicant Information:

Please Choose One:
Mr.    Ms.    Dr.   

________________________________________________________________
Name

________________________________________________________________
Title

________________________________________________________________
Company

________________________________________________________________
Street Address

________________________________________________________________
City                                          State                                           ZIP

________________________________________________________________
Phone Number                       Fax Number                              Email

Number of years in the industry _______________
How did you hear about ACC?

FORUM Beacon Awards Web Site

Referred By: ___________________ Other: ___________________

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Company Type:

Cable Network
Cable Company; Number of Customers: ___________________
State or Regional Association
Equipment Manufacturer
Consultant/ Public Relations Firm
Other: ____________________________________

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Occupational Emphasis

please limit your choice to three

Affiliate Relation/Sales Community Relations Education Financial

Government Relations Marketing Operations Production

Programmer Public Relations Other: _____________________

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Payment

Please mail completed application and payment of $200.00 to ACC at
P.O. Box 75007, Washington, DC 20013-5007,
Attn: Membership Services Coordinator.

Membership (good for 1 year) is neither transferable nor refundable. Membership service will begin 2-3 weeks after receipt of application.

Check Visa Mastercard American Express

Name on Card: ________________________ Card #: ________________________ Exp. Date: ________________________ Authorized Amount: ________________________