Information in this area will appear on the attendees list exactly as shown below.

Name ^*

(full name, as shown, will appear on badge)

Position ^*

(with pool/business)

Registrant's Email ^*

Registrant's preferred first name to appear on badge, if other than above

Pool/Business Name ^*

Address ^*

(Pool/Business mailing)

City ^*

State ^*

-- Select a State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth DakotaNorth CarolinaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBritish Columbia

Postal Code ^*

Country

-- Select a Country --AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanAzoresBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia & HerzegovinaBotswanaBrazilBritish Indian Ocean TerBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos IslandColumbiaComorosCongoCongo Democratic RepublicCook IslandsCosta RicaCote D IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea BissauGuyanaHaitiHawaiiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNambiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalau IslandPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbia & MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt HelenaSt Kitts-NevisSt LuciaSt MaartenSt Pierre & MiquelonSt Vincent & GrenadinesSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTahitiTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (Brit)Virgin Islands (USA)Wake IslandWallis & Futana IsWestern SaharaYemenZambiaZimbabwe (if other than USA)

If Registrant is a Pool Trustee or Board Member:

Employer

Job Title

(with employer)

Address

City

State

-- Select a State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth DakotaNorth CarolinaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBritish Columbia

Postal Code

Emergency contact phone number ^*

(to be used by registrar only)

Contact Name ^*

Relationship ^*

Special Needs Request - (food allregies, etc.)

(Includes Sunday reception, 3 breakfasts and 2 Lunches)

$675.00 Member Pool - First Registrant

$620.00 Member Pool - Additional Regs from same member pool

$675.00 Partner Member - Individual retaining an AGRiP Partner membership

$675.00 QEI Patron Employee

$865.00 All Others

$150.00 Spouse - Incl: Sunday reception, 3 breakfasts and 2 lunches

Full name for guest badge

$75.00 Late Registration - applied to registrations postmarked 10 business days prior to first day of Conference

For non-registered spouses or those not attending Conference sessions

Total fee due this registration only

$0.00

Name

Email

Submit