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PLC:

a005yt

Agency:

four states irrigation council

For:

sponsor/ exhibitor registration

Phone:

720-534-9176

Address:

220 water ave
berthoud, colorado 80513

*Required Field

Payment Information

Please provide registration information.

*Name:

Middle:

*Last:

*Company:

*Email:

*City:

*State:

*Website:

*Conference Attendance:

Presenting sponsor $1300

Banquet Sponsor $900

Luncheon Sponsor $700

Break Sponsor $575

Exhibitor $375

Additional Exhibitor (same company) $100

Awards Banquet With Registration $25

*Banquet Meal Choice (choose one):

Beef

Chicken

Vegetarian

Gluten Free

Not Attending

Additional Exhibitor 1 Name:

Banquet Meal Choice Additional Exhibitor 1 (choose one):

Beef

Chicken

Vegetarian

Gluten Free

Not Attending

Additional Exhibitor 2 Name:

Banquet Meal Choice Additional Exhibitor 2 (choose one):

Beef

Chicken

Vegetarian

Gluten Free

Not Attending

Notes:

Please calculate your total registration and enter it below

ERROR:

Payment Amount

Payment Amount :

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Subtotal:

$0.00

Service Fee:

$0.00

Total:

$0.00

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Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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