a Registration Form - Ohio Produce Growers & Marketers

June 24, 2015
Ramseyer Farms - Wooster, Ohio • Rittman Orchards - Doylestown, Ohio
#1 Company Information
#3 Attendee Information
Please print for each attendee
______________________________________________________
Company
Tour Registration
1. ______________________________________
Member
Non-Member
$20
$25
$10
$10
$10
$10
$10
$10
Full Name
______________________________________________________
______________________________________
Address
Email Address
______________________________________________________
City
State/Province
2. ______________________________________
Zip
Full Name
______________________________________________________
______________________________________
Country
Email Address
Company Email
3. ______________________________________
______________________________________________________
Phone
Full Name
Fax
______________________________________
______________________________________________________
Email Address
Company Website
4. ______________________________________
Select a primary business type: select only one
 Fruit Grower
 Educator
Full Name
 Fruit & Vegetable
 Vegetable Grower
 Roadside Farm Market/Store
 CSA Farm
 Student
 Retiree
Email Address
 Fruit & Vegetable Grower
 Farmers’ Market
 Ag Marketer
______________________________________
Registration Total $_________
 Other __________________
#4 Payment Information
#2 Membership Type and Dues
Select the membership type based on your business type
No refunds after June 20.
 I am already a member of OPGMA
Membership Total $_____ + Registration Total $______ = TOTAL DUE $________
 Produce & Marketer Membership Growers
 Visa  MC  AmEx  Check/Money Order (payable to OPGMA)
Please complete all of the payment information if paying by credit card.
CSAs, Farm Markets, etc.
Select dues level based on gross sales
 Up to $225,000
 $225,000 to $500,000
 $500,000 to $1 million
 $1 million and up
 Industry Partner
Supplier company to producers & marketers
Which of the following best describes your business type
 Up to $225,000
 $225,000 to $500,000
 $500,000 to $1 million
 $1 million and up
 Supporter
$120
$200
$300
$400
______________________________________________________
$120
Billing City
Billing Address
______________________________________________________
State/Province
Zip
______________________________________________________
$120
$200
$300
$400
$50
 Industry Partner
$25
 I am not a member and am not interested in saving money on registration
Membership Total $ ________
*Annual membership to OPGMA is nonrefundable. Members will receive mailings,
faxes, and emails from OPGMA and its approved partner organizations.
Credit Card Number
______________________________________________________
Expiration Date
V-code
______________________________________________________
Name on Card
______________________________________________________
Authorized Signature—I hereby agree to the terms and conditions of my card issuer
agreement.
P: 614-221-1900 • F: 614-221-1989
Mail: OPGMA • 17 S. High Street, Ste 200 • Columbus, OH 43215