INTERNET SERVICE PROVIDERS ASSOCIATION OF NIGERIA (ISPAN)

MEMBERSHIP REGISTRATION FORM

(Please note that this form must be completed and signed by the Chief Executive of the Company)

1. Company Name..................................................................... 

2. Service Name (The name by which your ISP business is known)......................

3. Address (location) ..............................................................

....................................................................................

4. Postal Address if different from the above ......................................

....................................................................................

5. Telephone .......................................................................

6. Fax .............................................................................

7. Email ................................................Website....................

8. Branches (if any) ...............................................................

....................................................................................

9. International affiliations (if any) .............................................

....................................................................................

10. Corporate membership of other organizations (state them) .......................

....................................................................................

11. Name of the Chief Executive of the company .....................................

12. Email of the Chief Executive of the company.....................................

13. Name of a  Top Management staff that can represent the company at 

ISPAN meetings/functions if the CEO is unavoidably absent ..........................

..........................................email address ............................

14. Certificate of incorporation number ..........................Date..............

15. NCC license number ..........................................Date...............

16. Date operation commenced or planned to commence ................................

17. Type of services provided. Please tick as appropriate
      
	Dial up .........  Wireless ...........  VSAT ............ DSL ...............
      
	VOIP ..........  Others (Please State) .......................................

8. Signature................................... Name ..............................

Title..........................................Date ................................

All duly completed registration forms should be accompanied by a cheque of N50,000.00 in favour of ISPAN