Universal Service: Pennsylvania
Registration Form

Name:    (Last)	  (First) 

Title:         	

Organization:   

School District:

Street Address: 

City:                State:  

County:             ZIP:  

E-mail: 	

Telephone: 	          FAX:	

Area of Employment:      Education
                         Library
                         Business
                         Government
                         Other

Preferred Distribution:  Mailing list (individual e-mail messages)
                         Mailing list digest (one big message 
                            e-mailed to you daily)
                         Web browser (no e-mail - you read 
                            messages on the Web)

How did you hear about the Universal Service: Pennsylvania seminar?

                         Announcement on mailing list
                         Notice on Web site
                         Personal e-mail message
                         Flyer in U.S. mail
                         Article in newspaper or journal
                         Word of mouth

How will your background help you contribute to the discussion?

What do you hope to learn from or accomplish in the on-line seminar?

Additional comments:

       Thanks for joining us!