AGRIWELLNESS, INC.

Conference
Registration

Name
Title
Organization
Address:
City, State, Zip:
Telephone:
Email:
Registration
Attendance:		 Yes, I plan to attend the reception!  PLEASE CHECK IF YOU PLAN TO ATTEND.

We are asking you to complete this online form for consumption purposes, to give us a better idea ahead of time what our head count will be. 

IT IS STILL NECESSARY FOR YOU TO COMPLETE PAGE 9 OF THE PDF REGISTRATION FORM, WHICH CANNOT BE COMPLETED ON LINE FOR SECURITY PURPOSES.

Click here to download the PDF file containing the registration form.

ONCE YOU HAVE COMPLETED THE REGISTRATION APPLICATION, YOU MAY CHOOSE ONE OF THE FOLLOWING PAYMENT OPTIONS:

  1. FOR NON-CREDIT CARD PAYORS: Complete the Registration Form on 
    Page 9     and send with your check (made payable to:  State Public Policy Group) to the following address:

RURAL AMERICA CONFERENCE
c/o State Public Policy Group
200 10th Street, 5th Floor
Des Moines, IA  50309

  1. FOR CREDIT CARD PAYORS MAIL OPTION: 
    Complete the Registration Form on Page 9  including your credit card information and SEND to the following address:

    RURAL AMERICA CONFERENCE
    c/o State Public Policy Group
    Des Moines, IA  50309

  2. FOR CREDIT CARD PAYORS FAX OPTION: Complete the Registration Form on Page 9  including your credit card information and FAX to:

    (515) 243-5941

For questions regarding the program content contact the AgriWellness, Inc. office at (712) 235-6100.  For questions regarding conference logistics, contact Deb Kazmerzak or Sally Johnson at (515) 243-2000.