Virtual Virtual Grower Grower Education Education Conference Conference Registration Registration Form Form Virtual Grower Education Conference Registration Form February 2-3, 2021 February 2-3, 2021 February 2-3, 2021
(It is important that you type or print legibly since each registrant will receive an access code via email.) (It is important that you type or print legibly since each registrant will receive an access code via email.) (It is important that you type or print legibly since each registrant will receive an access code via email.) Company Company Name: __________________________________ Phone: _________________________________ Company Name: __________________________________ Phone: _________________________________ Name: __________________________________ Phone: _________________________________ Registrant Registrant Name: 1)_________________________________ Registrant Name: 1)_________________________________ Registrant Name: 1)_________________________________ Registrant Name: 2)____________________________________ Registrant Name: 2)____________________________________ Registrant Name: 2)____________________________________ Registrant Name: 3)____________________________________ Registrant Name: 3)____________________________________ Registrant Name: 3)____________________________________ Registrant Name: 4)____________________________________ Registrant Name: 4)____________________________________ Registrant Name: Registrant Name: 4)____________________________________ 5)____________________________________ Registrant Name: 5)____________________________________ Registrant Name: 5)____________________________________ Registrant Name: 6)____________________________________ Registrant Name: 6)____________________________________ Registrant Name: Registrant Name: 6)____________________________________ 7)____________________________________ Registrant Name: 7)____________________________________ Registrant Name: 8)____________________________________ 7)____________________________________ Registrant Name: Registrant Name: 8)____________________________________ Registrant Name: 8)____________________________________ Registrant Name: 9)____________________________________ Registrant Name: 9)____________________________________ Registrant Name: 10)___________________________________ 9)____________________________________ Registrant Name: Registrant Name: 10)___________________________________ Name: 10)___________________________________ WPVGA Member Registration Fee
WPVGA Member Registration Fee WPVGA Fee $25 /Member person Registration Total due: $______ $25 / person Total due: $______ $25 / person Total due: $______ Payment by Check Payment by Check Payment by Check Please make checks payable to WPVGA and mail Please checks payable this formmake along with fees to: to WPVGA and mail Please checks payable this formmake along with fees to: to WPVGA and mail this form along with fees to: WPVGA P.O. Box 327 WPVGA WPVGA Antigo, WI 54409 P.O. Box 327 P.O. 623-7683 Box 327 (715) Antigo, WI 54409 Antigo, WI 54409 (715) 623-7683 (715) 623-7683
44 BC�T January
Email:_______________________________________ Email:_______________________________________ Email:_______________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Email:___________________________________________ Non-WPVGA Member Registration Fee
Non-WPVGA Member Registration Fee Non-WPVGA Member Registration Fee $40 / person Total due: $______ $40 / person Total due: $______ $40 / person Total due: $______ Payment by Credit Card Payment by Credit Card Payment___Mastercard by Credit Card ___AmEx ___Visa ___Discover ___Visa ___Discover ___Mastercard ___AmEx ___Visa ___Discover ___Mastercard ___AmEx Cardholder’s Name:______________________________________ Cardholder’s Cardholder’s Name:______________________________________ Name:______________________________________ Card Number: ___________________________________________ Card Number: Card Number: ___________________________________________ ___________________________________________ Expiration Date: _____ / _____ Expiration Date: _____ / _____ Expiration _____ / _____ VerificationDate: Code:_________ Verification Code:_________ Verification Code:_________ Email this form to jbraun@wisconsinpotatoes.com or fax this to (715) Email form623-3176. to jbraun@wisconsinpotatoes.com Email form623-3176. to jbraun@wisconsinpotatoes.com or fax this to (715) continued on pg. 46 or fax to (715) 623-3176.