SouthWest Crop Diagnostic Day Registration Information
Name:
Company:
Address:
City:
Postal Code:
Phone:
Fax:
E-mail:
Check a Date:	Wednesday, July 6th - Thursday, July 7th
Check a Payment Method:	Cheque ** - Credit Card: VISA - MasterCard - American Express All Prices include HST, $95.00 per person
Card Number:
Expires:
Name on Card:
** If paying by cheque, please make cheque payable to "Southwest Crop Diagnostic Day".
The personal information collected on this form is collected by Ontario Ministry of Agriculture, Food and Rural Affairs (OMAFRA) under the authority of the Ministry of Agriculture, Food, and Rural Affairs Act, R.S.O. 1990, c.M.16 and will be used by OMAFRA for the purposes of registration and payment for the Southwest Crop Diagnostic Day. Questions about the collection by OMAFRA should be directed to the Field Crop Manager, Agiculture Development Branch, Economic Development Division, Ministry of Agriculture, Food and Rural Affairs, 1 Stone Road West, 3rd Floor, Guelph, ON, N1G 4Y2, 519-826-3257. Please check the appropriate box below: Yes No I consent to my personal information being used by OMAFRA for future mailings of the Southwest Crop Diagnostic Day brochure mailings. Further, the information will be provided to the Southwest Soil and Crop Improvement Association for the purpose of payment processing. Questions about the collection of information by Southwest Soil and Crop Improvement Association should be directed to the President of Southwest Soil and Crop Improvement Association at 519-352-2950. By signing this form I acknowledge and confirm that I have read the statement above. (your signature here) ______________________________
Registration Options: 1) Mail this Registration form (with payment) to: OMAFRA Resource Centre Southwest Crop Diagnostic Day Box 400, Ridgetown, ON, N0P 2C0 2) Fax: OMAFRA Agricultural Information Contact Centre Fax: 519-539-5351 (VISA, Mastercard and American Express) 3) Phone: OMAFRA Agricultural Information Contact Centre Toll Free: 1-877-424-1300 (VISA, Mastercard and American Express)