Primary Attendees: $785 Spouses: $585 Please send checks Payable to VPDA to: Viking Pump Attention: Debbie Kleitsch 406 State Street Cedar Falls, Iowa 50613 First name (as it appears on name badge) Last name (as it appears on name badge) Company Email Phone Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon I approve the sharing of my email and phone number with fellow participants Shirt Size - Select -SmallMediumLargeX-Large2X-Large3X-Large4X-Large Dietary or Physical Requirements Do we have your permission to use your image in social media and marketing? Yes, you may use my image No, you may not use my image Are you bringing a spouse? Yes No Spouse First name (as it appears on name badge) Spouse Last name (as it appears on name badge) Spouse Email Spouse Phone Spouse City Spouse State Spouse Dietary or Physical Requirements My spouse approves the sharing of their email and phone number with fellow participants. Do we have your spouse's permission to use their image in social media and marketing? Yes you can use my image No you may not use my image I/We plan on participating in the scheduled activity We will assume that you are participating in the activity scheduled for Spouse / Guests unless noted here Submit Registration
